While the discovery of deep pocketing seems to be the most common cause of alarm during periodontal exams, soft tissue deficiencies are often overlooked during routine exams. This is problematic as soft tissue deficiencies may worsen without obvious signs of disease, cause restorative difficulty, and may contribute to tooth loss. Treatment of soft tissue deficiencies also becomes progressively more difficult and unpredictable with increasing size of defect and with time, it may become untreatable.
Case
A 57-year old Caucasian female with a history of total joint replacement, gastroesophageal reflux disease, and sulfa drug allergy takes 10 mg pantoprazole once daily and is interested in improving the uneven appearance of her front teeth with the left-side canine appearing longer than any teeth on the right side. She has received regular periodic dental treatment in the past including restorative treatment, endodontic treatment, and orthodontic treatment. Restorative treatment was originally done to treat caries she had as a young adult, and these restorations have been replaced several times since. She also received restorations to fill in erosion lesions on the facial surfaces of teeth that appeared over time. Root canal therapy for tooth no. 3 was done decades ago. Orthodontic treatment was done to relieve severe crowding when she was a teenager, and involved removal of tooth no. 6 and no. 24. She wears a fixed wire retainer on the lingual side of the mandibular incisors. She reported that she clenches her teeth at times during the day, and is interested in an occlusal guard. For oral hygiene, she brushes her teeth twice a day with an Oral-B brush in a sweeping motion running from the gingiva to the facial surfaces, and flosses 2 to 3 times a week.
The extraoral exam does not produce any significant findings with no enlarged lymph nodes, normal muscle palpation, and normal opening range. Intraoral tissues appear all normal except with marginal gingival inflammation at some teeth. Salivary flow is normal and glands palpate normally. Teeth are generally clean and in good repair, although there is attrition on all occlusal surfaces and staining of restorative margins. The patient’s occlusion fits the Angle Class I pattern, and teeth display group function during excursive movements.
Blood pressure is 120/90 mm Hg and the pulse is 59/min.
The area of concern are shown in (Fig. 8.1).
The periodontal findings for the maxillary teeth are as follows:
Oral hygiene instruction was provided to make sure that the patient could maintain low plaque levels without using an aggressive brushing technique. The old composite restoration at tooth no. 11 was removed as it was stained and had a pitted margin and replaced it with a resin-modified glass ionomer restoration with the same coronal margin position. Prior to surgery, a rigid palatal stent was fabricated to cover and protect the palatal donor site during wound healing. Connective tissue graft surgery was performed, which reduced recession, thickened the gingival margin, and produced improved appearance (compare before and after on Fig. 8.1). Healing was uneventful with no bleeding after surgery, moderate pain only for one day, and no pain within days after the surgery. Within 3 months, tissue appearance matched the surrounding teeth and the teeth in this quadrant had even gingival margins to the satisfaction of the patient. Additional corrective treatment was planned for other quadrants and scheduled as the patient’s finances allowed.
What can be learned from this case?
While this patient presented with no severe periodontal disease as evidenced by low probing depths, little or no attachment/bone loss, good oral hygiene, and little bleeding on probing, this patient has multiple mucogingival conditions. As this patient was bothered by the recession at tooth no. 11, treatment was indicated. This patient presented with several factors that may have contributed to the recession such as orthodontic treatment, facial restorations, and parafunctional habits. Aggressive tooth brushing can contribute to facial recession, but in this case, there is limited evidence for it although her oral hygiene regimen could be improved regarding interproximal care.
Resin-modified glass ionomer was used to provide a more hydrophilic surface that promotes tissue adaptation and reduces caries risk as the restoration is now partially submerged in soft tissue. The corrective surgery showed key features of connective tissue graft surgery such as excellent color match, improved root coverage, and tissue thickness with little scarring. Given that the contributing factors for recession in this area occurred in the past, the risk of new recession development in this area seems low.
Recognize Indications for Mucogingival Surgery
While periodontal treatment usually focuses on reducing inflammation and pocketing, achieving proper soft tissue dimensions and characteristics is also important for periodontal health.
Risks Associated with Gingival Recession
Normal physiologic gingival contours with gentle scalloped facial and lingual margins support good oral hygiene and protect the underlying cementum and dentin from exposure to the oral environment. Gingival recession that exposes root surfaces often presents an esthetic concern. The exposed root surfaces usually are darker than the enamel and are more likely to stain and adhere plaque given the rougher surface of dentin and cementum compared to enamel. These surfaces are also softer and less mineralized than enamel, and prone to root caries, which then necessitate restoration that is different from a natural, healthy tooth surface. Gingival recession also tends to be uneven in severity, resulting in longer and uneven appearing teeth as seen in the case described above.
Besides the esthetic concern, exposed root surfaces also tend to be sensitive, causing short-lived, but intense pain whenever cold material touches the sensitive surface. Sometimes, sensitivity is severe enough that even touching the sensitive surface causes pain.
Ideally, therefore, gingival recession should be avoided and corrected wherever possible. Practically, it is not possible to revert most areas of gingival recession given that it often is the result of irreversible tissue damage caused by periodontal disease. As the ideal situation cannot be attained in most patients with periodontitis, periodontal treatment presents in these patients as a compromise: pocket reduction is traded against increased recession since this allows easier periodontal maintenance and lower risk of tooth loss. The consequent recession then has to be managed with patient education, oral hygiene instruction, fluoride application, and application of desensitizing medications to guard against the consequences of gingival recession.
Causes of Gingival Recession
The following factors are associated with gingival recession, and are often the cause of gingival recession:
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Gingival inflammation: Gingival recession often follows attachment and bone loss seen in periodontitis, as the continued destruction of gingival fibers and supporting tissue will cause apical migration of the gingival margin. In many populations, gingival inflammation linked to plaque and calculus deposits is most associated with gingival recession.1 For similar reasons, older age and male gender are associated with gingival recession, as older and male patients tend to have more severe periodontal disease. For diagnosis, gingival recession caused by persistent inflammation most likely will be interproximally as these sites commonly have the worst plaque level, and there will be signs of significant periodontal disease. For treatment, this means if a site with gingival recession is associated with inflammation, plaque, and calculus build-up, oral hygiene instruction and scaling and root planing need to be performed in order to prevent further tissue damage.
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Smoking and use of smokeless tobacco: These factors are often associated with gingival recession as tobacco use will exacerbate periodontal disease leading attachment loss and destruction of gingiva-supporting tissue. Smoking history or exacerbated recession in the area of smokeless tobacco placement will suggest this cause in addition to enhanced periodontal disease. Consequently, periodontal therapy will need to include tobacco-cessation counseling in this case.
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Aggressive tooth brushing: Aggressive brushing or using a hard toothbrush has long been associated with gingival injuries, facial gingival recession, and abrasion of tooth surfaces, although this relationship is not seen in all studies.2 Clinically, this can be evaluated by observing the patient while the patient performs oral hygiene, and noting aggressive brushing techniques. In case of aggressive tooth brushing, recession will be most pronounced at teeth that protrude from the arch such as the canines.
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Piercing: Labial or tongue piercing is associated with gingival recession adjacent to the tongue or lip ornament, and patients should be discouraged from wearing intraoral piercings.
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Occlusal trauma: This has long been associated with gingival clefting and some studies suggest a general relationship between occlusal interference contacts and localized gingival recession.
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Chronic trauma: Chronic trauma from restorative factors (that is ill-fitting RPD clasps) or destructive habits may cause localized recession.
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Orthodontic therapy: This is associated with slightly increased gingival recession, but only in few patients this is clinically significant and orthodontic tooth movement can also correct gingival recession in some cases. While labial tooth movement may produce gingival recession, it is more likely that other factors such as aggressive tooth brushing and reduced tissue thickness at the new tooth position may predispose the patient to increased recession. In our experience, this typically becomes a problem in mandibular incisors if there is limited symphysis bone and thin gingiva.
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Thin gingival tissue thickness: Thin gingival tissue is more likely associated with gingival recession.
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Frenum pull: High frenum attachment is sometimes associated with gingival recession, usually at the facial surfaces of the central incisors, and occasionally near premolars. Frenum pull can be identified by moving the lip and cheek tissues with finger pressure, and observing the mucosa for any tissue bands that pull and blanch the gingiva coronal to these tissue bands.
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Soft tissue disorders: Very rare, soft tissue diseases such as mucous membrane pemphigoid are associated with increased gingival recession as the gingiva cannot hold up against normal forces of chewing and brushing.
Risks Associated with Lack of Keratinized Tissue
Another factor that is associated with gingival recession is lack of keratinized gingiva. However, this association is more controversial as various cross-sectional studies show a relationship, whereas several cohort studies failed to find a significant association.
The determining factor, if a site without sufficient keratinized gingiva is prone to develop recession, is inflammation caused by either plaque accumulation or presence of a subgingival restoration that irritates the local tissues. Teeth without sufficient keratinized gingiva are more likely to have higher plaque scores and inflammation, presumably because brushing these teeth is more uncomfortable as toothbrush bristles scrape up against the more delicate mucosa.
While dental implants lack the gingival attachment mechanism of teeth, the question of how much keratinized gingiva is needed to maintain healthy periimplant tissues is similarly controversial. As with teeth, some studies suggest that lack of keratinized gingiva is associated with more inflammation,3 while other studies fail to show clear evidence for this relationship. Currently, the evidence seems to favor the idea that sufficient amount of keratinized gingiva around implants is better for long-term health and implant survival. The key factor again is oral hygiene, and presence of keratinized gingiva allows for easier hygiene and implant maintenance.
Causes of Insufficient Keratinized Gingiva
The position of the mucogingival junction is likely determined by genetic factors controlling the growth of the jaws and differentiation of oral epithelial cells. Therefore, some individuals are born with low amounts of keratinized gingiva and are more prone to have mucogingival defects. For any individual, lack of keratinized gingiva develops if periodontal disease destroys the marginal gingiva and the gingival margin approaches the fixed mucogingival junction.
How much Keratinized Gingiva Is Needed?
Generally, for implants, it appears that at least 2 mm of keratinized mucosa are needed for improved health. For teeth, this question depends on oral hygiene and if a subgingival restoration is needed as teeth without attached gingiva may never develop recession in the absence of gingival inflammation. For teeth that need restoration, the minimum requirement seems to be at least 2 mm of attached gingiva, and there is one recommendation for 5 mm of keratinized mucosa that includes 3 mm of attached gingiva.
Tissue Thickness, Biotype, and Restorations
Thin gingival tissue poses a greater risk for recession, reduces effectiveness of regenerative procedures, and is easily injured during restorative procedures leading to additional recession.
Thin gingival tissue is associated with a thin biotype, and has the following characteristics:
The Problem of High Frenum Attachments
While frenum attachments are part of normal oral anatomy, a frenum may attach too close to teeth resulting in local lack of keratinized gingiva or a diastema. Such high frenum attachments can be detected by moving the cheek and lips in various directions, and observing how close the frenum inserts to the gingival margin. High frenum attachments should be removed if they cause or are associated with:
Importance of Sufficient Vestibular Depth
The vestibule is nearly always overlooked during periodontal exams, but vestibular depth may be important for some patients. Typically, the vestibular fold is about 6 to 7 mm apical to the facial gingival margin in the anterior mandible and often this is the area with the shallowest vestibule. While a shallow vestibule by itself usually is not detrimental to periodontal health, teeth in an area of shallow vestibule tend to accumulate plaque and calculus as the shallow vestibule restricts brushing and interproximal cleaning. A shallow vestibule makes retention of dentures more difficult and may also make impression taking more challenging. Shallow vestibular depth also seems to have a negative effect on the health of periimplant tissues.4
Surgical procedures, such as the lateral sliding flaps or pedicle flaps, require a sufficiently deep vestibule to allow execution of the surgery procedure. Other surgical procedures such as bone augmentation procedures may shorten the vestibule, which then can cause oral hygiene problems unless this is corrected with another surgery step.
Medical Contraindications
Surgeries that correct soft tissue defects should not be performed in the presence of uncontrolled medical conditions. Typically, such surgery causes more bleeding than pocketreduction surgery and relies more on soft tissue healing. Therefore, patients with bleeding disorders or taking anticoagulants and antiplatelet agents require medical collaboration, and the procedure may not work well in patients with immune and soft tissue disorders.
Dental Contraindications
There are few if any dental contraindications to mucogingival surgery. Mucogingival surgery is easier to perform and likely has better clinical outcomes if the local gingiva is healthy. For this reason, it is usually advisable to correct pocketing and inflammation prior to mucogingival surgery.
Root coverage procedures are more challenging to perform on tooth roots that excessively protrude outside of the dental arch. Orthodontic treatment may help with root coverage procedures if it lines up teeth and reduces root prominence. Consequently, any orthodontic treatment should be completed before mucogingival surgery.
A shallow vestibule makes it difficult to create a pedicle flap or good recipient site for a connective tissue graft. Coronally positioned flaps actually worsen a shallow vestibule by repositioning the gingiva and mucosa even more coronally. In these cases, procedures that increase vestibular depth such as free gingival graft, an apical positioned flap, or vestibuloplasty should be considered.
Consent Issues
As with any surgery, informed consent must be obtained by discussing risks, benefits, and alternatives with the patient.
The specific benefit of mucogingival surgery depends on the specific need it addresses, but in general, mucogingival surgeries promote tooth longevity as they improve oral hygiene, cover sensitive root surfaces, and provide greater resilience during restorative treatment.
The risks of mucogingival surgery are similar to most oral surgery procedures. The most common risk are prolonged bleeding after surgery, moderate pain, and swelling of the treated tissue. For soft tissue grafting, the surgery site may undergo color changes from gray over purple and red to pink during healing. As with any surgery, there is a chance that mucogingival surgery may fail to produce the desired results.
The alternative to mucogingival surgery usually is not to perform the surgery. Often, mucogingival conditions worsen little over long periods of time if the original cause has been removed, and regular periodontal maintenance is a valid alternative to most mucogingival surgery, although the condition may become worse over time.
Create Treatment Plans that Prevent, Manage, or Correct Mucogingival Problems
Mucogingival conditions such as recession, lack of keratinized tissue, excessively thin tissue, frenum attachments, and shallow vestibule should be treated if any of the following conditions is present.
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Signs of periodontal inflammation: Pocketing, erythema, or edema.
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Evidence that condition is getting worse, i.e., increased recession and attachment loss at subsequent maintenance visits.
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Evidence that condition interferes with oral hygiene, i.e., persistent plaque and calculus accumulation that does not improve despite improved patient effort.
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If the patient has an esthetic concern specific to gingival appearance, and it is correctable with surgery.
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Dentinal hypersensitivity in an area of isolated facial/lingual gingival recession.
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Root caries associated with isolated facial/lingual gingival recession.
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Lack of keratinized tissue or tissue thickness on a tooth that needs a restoration at or below gingival margin.
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Lack of keratinized tissue, thickness, or root coverage, high frenum attachment in an area that will receive orthodontic treatment.
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Lack of keratinized tissue or tissue thickness, high frenum attachments in an edentulous area that will receive periodontal or implant-related surgery.
Prevention of Mucogingival Problems
Since definite correction of mucogingival problems usually requires surgery, it is best to avoid the development of mucogingival problems in the first place. Therefore, risk factors for gingival recession, such as gingival inflammation, tobacco use, intraoral piercings, and aggressive tooth brushing, should be assessed at every dental exam and addressed promptly.
The importance of oral hygiene instruction in preventing mucogingival problems cannot be overstated as in our experience many patients adopt overly aggressive tooth brushing techniques in the hopes of “brushing pockets away.” Recently, there is some evidence that teaching patients gentle, but effective plaque-removal techniques can lead to minor improvement of gingival recession over time.5 For patients with aggressive brushing habits, we recommend using a modified Stillman technique using a toothbrush with extrasoft bristles (i.e., Nimbus Microfine brush) and low abrasive dentifrice (i.e., pure baking soda or Arm & Hammer PeroxiCare toothpaste).
In order to prevent the development of mucogingival problems as a result of dental treatment, soft tissue dimensions need to be assessed prior to restorative treatment or orthodontic treatment. If tissue amounts are deficient, the patient needs to be advised of the possibility of recession development and corrective mucogingival surgery should be planned after orthodontic or restorative treatment.
Management of Mucogingival Problems
Treatment of mucogingival problems involves first identifying the mucogingival problem, correcting contributing factors and planning the corrective procedure(s) for each mucogingival problem.
Identifying the Mucogingival Problem
For any tooth or site with a mucogingival problem, it is important to identify each mucogingival deficiency and determine its importance for the patient and for dental treatment. Mucogingival problems can be categorized as follows:
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Recession/lack of root coverage. If this is a concern, note:
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Lack of keratinized/attached gingiva in the absence of deep probing depths:
Since many mucogingival procedures harvest intraoral soft tissue for grafting purposes, it needs to be determined if:
Prognosis of Treatment Success
For recession/root coverage, many classification systems have been developed (i.e., Sullivan & Atkins, Miller) to aid with treatment planning and prognosis, but have limitations.6 In general, the likelihood of gaining root coverage depends on the factors shown in Table 8.2.
For gaining keratinized gingiva, the likelihood of success depends mostly on surgical and patient factors (Table 8.3).
Gaining tissue thickness is very predictable, and mostly depends on surgical skill of the surgeon and general wound healing ability of the patient. Similarly, frenectomy and vestibuloplasty procedures are predictable as long as sound surgical skills are used and the patient is able to heal normally.
When to Refer
If the condition is stable based on past records, and not a concern for the patient or treatment, mucogingival conditions can be managed with periodic evaluation, routine periodontal maintenance, and oral hygiene instructions that emphasize on gentle cleaning techniques.
However, definite treatment of mucogingival conditions typically requires surgery and the success of the surgery depends largely on surgical skill. Consequently, referral to a periodontist is usually warranted for most but the simplest procedures. The major prerequisite skill for these surgeries is the ability to raise a split thickness flap, and handle delicate thin tissues that are difficult to suture. Mucogingival surgeries range in difficulty level from relatively easy to difficult in the following way:
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Placing a free gingival graft over a frenectomy site to prevent frenum attachment in a nonesthetic site (i.e., mandibular vestibule apical to central incisors).
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Augmenting a posterior edentulous site with limited keratinized tissue/vestibule prior to implant placement or removable partial denture construction.
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Augmenting thin gingival tissue at a posterior tooth with a connective tissue graft.
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Complex grafting involving multiple teeth or a combination of procedures.
Treatment Planning
Planning surgical correction of mucogingival defects can be complicated and it is dependent on a particular surgeon’s preference for a given technique. In general, treatment planning begins with identifying the nature of the mucogingival problem(s) and selecting the procedure that addresses the problem(s) best. Sometimes, it is possible that several surgeries have to be combined in sequence to achieve the desired effect (Table 8.4).
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