It was a pleasure to read Dr Pickron’s response to our article, and we sincerely appreciate the interesting and constructive comments. On the other hand, it is paramount to further the discussion in regard to some key aspects in our clinical example.
In our article, we presented a 30-year-old woman with malpositioned mandibular incisors and roots positioned outside the alveolar bone related to severe localized gingival recession. In the letter, Dr Pickron mentioned: “But by casting blame on previous orthodontic treatment, I believe that the authors may have overlooked the etiology of gingival recession.” We understand that this issue is a delicate topic in orthodontics. It is difficult to judge someone else’s work, especially a colleague’s. For this reason, it is vital to assess all information about the patient’s medical and dental history. Based on information provided by the patient, she did not have gingival recession before her previous orthodontic treatment. In addition, there was no notable medical history, and no use of medications or tobacco, and she had good oral hygiene. After we carefully analyzed those aspects, what was the etiology of her localized gingival recession?
The etiology of gingival recession is multifactorial. Previous studies have identified that poor oral hygiene, periodontal disease, use of tobacco, inadequate restorations, frenal pull, and insufficient tooth posistion might be factors that play a role in the progression of gingival recession. Also, researchers have concluded that if orthodontic treatment is performed without accuracy, it can lead to gingival recession.
In our article, we did not blame the previous orthodontic treatment as an etiology of gingival recession. On the contrary, we stated in the Discussion that “it can be hypothesized that the etiology of the gingival recession in our patient was related to plaque accumulation or toothbrush trauma and to previous orthodontic treatment with subsequent placement of the mandibular incisor roots outside the alveolar bone.” It is clear that interplay between different factors might have played a role in the etiology of the gingival recession. However, the question still remains: were the malpositioned mandibular incisor roots caused by an iatrogenic treatment? Or as Dr Pickron suggested, “the mandibular bonded lingual retainer might have been the primary cause of postactive orthodontic root movement and subsequent gingival recession.” We applaud Dr Pickron’s biomechanical explanation concerning how a flexible mandibular bonded lingual retainer can cause unwanted root movements, and that position was recently published.
However, we cannot correlate this unwanted movement as a “primary cause of postactive orthodontic root movement and subsequent gingival recession,” as he stated. Up to this point, no evidence of such etiology has been demonstrated in randomized clinical trials or case studies.
One key characteristic that helps to solve this puzzle is that in our clinical example the previous orthodontist referred the patient for 2 gingival grafts after fixed orthodontic therapy. What makes this event even more intriguing is that both gingival procedures yielded unsatisfactory results. After we analyzed this treatment approach, several questions arose. Why did the previous orthodontist refer the patient for a gingival graft? Why was the gingival graft undertaken at 2 different times? Instead, why not reposition the roots within the alveolar bone before undergoing surgery? We understand that there are no answers for such questions; nevertheless, from the ortho-perio standpoint, the previous multispecialty treatment was far from ideal.
Another feature that makes our case different from the one Dr Pickron mentioned is that the gingival recession described by the authors was present after a 5-year follow-up with mandibular fixed retention. In such a scenario, interplay among several factors such as active orthodontic root movement by the wire and onychophagia may cause localized gingival recession. In our case report, gingival recession was present after fixed orthodontic treatment, and that was the main reason that the patient was referred to a periodontist.
We corroborate the notion that in the long term, a mandibular bonded lingual retainer can cause unwanted dental movement. Although this was not the primary etiology in our patient, we suggest long-term follow-up for routine reevaluations.
As orthodontists, we hope to rarely face iatrogenic cases, since they pose difficult problems not only technically, but also psychologically.