14: Gingival recession

Chapter 14

Gingival recession

Introduction

Gingival recession is defined as the apical migration of the gingival margin below the cementoenamel junction, resulting in exposure of the root surface. It can be localized or generalized and is a common problem that can be caused by periodontal disease, periodontal treatment, or chronic trauma in otherwise periodontally healthy patients. Recession can sometimes be self-limiting and cause few problems, but it can also result in a range of problems for patients and represents a difficult challenge to manage.

The principles of management of gingival recession include the following:

Assessment of the aetiology of the condition

Identification of the patient’s concerns about the condition

Removal of any aetiological factors when possible

Monitoring the stability of the recession

Management of any sequelae of the condition, such as dentine sensitivity

In some cases, correction of the gingival recession is indicated

Assessment

In assessing gingival recession, a careful history of the condition needs to be taken followed by clinical examination to assess the extent and severity of the condition and to identify the aetiology. A list of the aetiological factors of recession is shown in < ?xml:namespace prefix = "mbp" />Table 14.1. A key factor in most cases of recession is the associated anatomical factors that predispose to the condition. The major determinant of many cases of recession is the thickness of the gingivae, which is referred to as the gingival biotype. Recession mainly occurs where there is a thin gingival biotype and where the gingiva is thin because of its position, such as the labial gingivae of the lower incisor regions or labial gingivae of the upper canine teeth. In some cases, the biotype is sufficiently thin that developmentally there is no labial alveolar bone, known as a dehiscence. In these cases, gingival recession can develop rapidly in the presence of chronic minor trauma, such as toothbrushing and possibly even from the minor trauma from everyday masticatory loads. Where a tooth is malpositioned, such as proclined or rotated, this can again result in the absence of overlying alveolar bone because the tooth root is now outside the envelope of the alveolar bone.

Table 14.1 Aetiological factors in gingival recession

Aetiological factor Specific examples Comments
Chronic trauma Particularly vigorous toothbrushing; also habitual trauma such as picking at gums and from tongue studs; direct trauma to gingivae from opposing teeth due to malocclusion Usually gingivae healthy and uninflamed; seen particularly where there are associated anatomical factors such as thin gingival biotype
Gingival biotype Thickness of the gingivae varies considerably between patients and at different sites in the mouth; bony dehiscences Typically affecting labial surfaces of lower incisors and upper canines
Malocclusion Proclination or rotation of teeth, resulting in root surfaces outside the bony envelope of the jaws, creating bony dehiscences Similar effect to thin gingival biotype
Frenal attachments/lack of attached gingivae Typically labially on lower anterior teeth Frenal pulls may directly enhance recession but also may impair plaque control
Periodontal disease Although attachment loss in periodontitis usually causes pocketing, where predisposing anatomical factors present it may result in recession instead Gingivae inflamed and plaque accumulation evident
Smoking Smoking reported to increase gingival recession  
Periodontal treatment All types of periodontal treatment can result in some recession; most marked in pocket elimination surgery (apically positioned flaps) in which recession is a deliberate outcome Widespread and generalized with loss or recession of interdental papillae; determined by the amount of underlying bone loss
Overeruption of teeth Due to tooth wear or lack of opposing teeth  

Anatomical factors of the soft tissues may also play a major role in the aetiology of recession. These are particularly related to the presence of frenal attachments, especially in the lower labial mucosa. A high frenal attachment may extend close to the gingival margin of the tooth, and there may also be an associated lack of attached gingiva, such that the forces during, for example, mastication are directly transmitted to the gingival margin and promote recession. In addition, high frenal attachments may also impair adequate plaque control in the region, resulting in localized periodontal disease that manifests as recession.

Gingival recession defects can be classified according to Miller’s classification, which grades the severity of defects according to whether the recession extends to the mucogingival junction and whether it has resulted in interproximal attachment loss and recession of the interdental papilla (Table 14.2). Miller’s classification is particularly applied to defects when being considered for corrective surgery, with those classed as I or II considered amenable to surgical intervention and those classed as III or “IV” considered not amenable.

Table 14.2 Miller’s classification of gingival recession defects

Class I: Defect that does not extend to mucogingival junction

Class II: Defect that extends to the mucogingival junction, but with no interproximal attachment loss

Class III: Recession that includes loss of attachment interproximally

Class IV: Severe recession involving extensive interproximal attachment loss

By itself, gingival recession may often be localized, self-limiting, and harmless. However, in many cases, there are important sequelae associated with the condition, and it is important to assess these when deciding on the management of recession. A list of problems associated with gingival recession is shown in Table 14.3. Patients with localized recession associated with chronic minor trauma such as toothbrushing typically have very clean, healthy mouths and no associated periodontal disease, but they often are concerned that the condition is indicative of generalized periodontal disease and worry about the risk of eventual tooth loss. In these cases, patients need to be carefully reassured that the condition is not indicative of periodontitis and that tooth loss is actually a very rare consequence of progressive recession in these cases. The assessment and management of gingival recession is illustrated in the cases presented next.

Table 14.3 Problems associated with gingival recession

Progression of recession—ultimately endodontic involvement and tooth loss

Dentine sensitivity

Risk of root caries

Tooth surface loss—erosion and abrasion of root surfaces

Poor aesthetics

Case 1

A 46-year-old man presented complaining of generalized gingival recession. He had been aware of the recession for a number of years but believed that it had become noticeably worse in the past 12 months. He had persisting tooth sensitivity to cold stimuli but was not concerned about the appearance of the recession because he believed that his lips concealed the recession. He was also concerned about the risk of tooth loss in the long term. He was medically fit and well and a nonsmoker.

He was brushing his teeth four times a day with a hard toothbrush. He had a low-sugar diet and drank approximately 1 L of orange juice every day. He had previously used a toothpaste for sensitive teeth but was not currently using this.

The clinical appearance at presentation is shown in Figure 14.1. The main feature of note is the marked labial recession seen in both upper and lower incisor teeth. The interdental tissues were unaffected. The recession defects were classified as Miller class I because they do not extend to the mucogingival junction and do not involve the interdental tissues. Some tooth surface loss of the exposed root surfaces was evident. The appearance of this was consistent with a combination of abrasion and erosion arising from the toothbrushing and the high acidic dietary intake. The patient had excellent plaque control, and there was no gingival bleeding or other signs of periodontal disease elsewhere. A full chart of the recession was made. He was asked to demonstrate his toothbrushing method, which consisted of a vigorous scrubbing action with his hard manual toothbrush. The clinical examination noted the thin gingival biotype on the anterior teeth.

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Jan 5, 2015 | Posted by in Implantology | Comments Off on 14: Gingival recession
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