Gingival Recession


Gingival Recession

Type VIII B 1

Recession of the marginal gingiva (classified as Type VIII B 1) may result from various etiologies, and can occur in various clinical manifestations, including combined forms:

  • “Classical” recession occurs in the absence of any infection, is inflammation-free, and is usually localized to the facial surfaces. It is the most common type of gingival recession, normally without loss of the interdental papillae (Figs. 349350).

  • Recession attendant to untreated periodontitis (most often the chronic forms): It progresses slowly, often over many years, and involves both marginal gingiva and papillae (Fig. 358).

  • Loss of the marginal and interdental gingiva often occurs following periodontitis therapy, especially when resective treatment methods are employed (Fig. 359).

  • Recession is a manifestation of the involution of aging, with retraction/recession of marginal and usually also the interdental gingiva (Fig. 360).

“Classical” Recession

Classical recession accounts for 5–10% of all periodontal attachment loss. The term recession is defined as an inflammation-free clinical condition characterized by apical retreat of the facial and less often of the oral gingiva. Despite recession of the gingival margin, the interdental papillae usually fill the entire embrasure area in younger patients. Recession is usually localized to one or several teeth; generalized gingival recession is rare. Teeth exhibiting classical gingival recession are not excessively mobile. The periodontal supporting structures are generally of excellent quality. Teeth are never lost due to classical gingival recession alone! If the patient’s oral hygiene is inadequate, secondary inflammation and eventually pocket formation (periodontitis) may ensue.

Etiology: A primary factor is purely the morphology and the anatomy of the situation. The facial plate of bone overlying the root is usually very thin. Not infrequently, the root surface is completely denuded of alveolar bone (dehiscence), or exhibits fenestrations in the thin osseous lamella. Anterior teeth and premolars are most frequently affected.

Recession is initiated as a consequence of the morphologic/anatomic situation, and the following etiologic factors:

  • Improper, traumatic tooth brushing, e.g., horizontal scrubbing, excessive force (Mierau & Fiebig 1986, 1987)

  • Mild, chronic inflammation that may be only slightly visible clinically (Wennström et al. 1987a)

  • Frenum pulls, especially when fibers of the frenum attach near the gingival margin

  • Orthodontic treatment (tooth movement labially; arch expansion; Foushee et al. 1985; Wennström et al. 1987a)

  • Excessive periodontal scaling (Caution at recall!)

  • Functional disturbances (e.g., bruxism) as the cause for gingival recession continue to cause heated discussion.

“Classical” recession is illustrated in the following pages graphically, on skull preparations and clinically.

Radiographically, pure gingival recession localized to the facial surfaces of teeth cannot be diagnosed.

Therapy: With scrupulous and proper oral hygiene, recession can be halted. An atraumatic tooth brushing technique with a soft manual brush or a sonic device should be recommended.

Severe types of recession may require mucogingival surgery.

Fenestration and Dehiscence of the Alveolar Bone

In a healthy periodontium the facial margin of the alveolar crest lies approximately 2 mm apical to the gingival margin, which courses near to the cementoenamel junction. The facial aspect of the alveolar bone covering the root is usually very thin. As revealed by a flap operation or on a skull preparation the coronal portion of the root often is not covered by bone (dehiscence) or there is a fenestration of the facial bony plate. Towards the apex, the facial plate of bone becomes thicker and trabecular bone fills the interval between the facial cortical plate and cribriform plate. In these thicker areas, recession generally stops spontaneously.

In elderly individuals, especially in those who have practiced excessive interdental hygiene for many years, recession of facial periodontal tissues may appear in combination with horizontal bone loss in the interdental area. In such cases, the interdental papillae usually also recede. Nevertheless, no true periodontal pockets are in evidence.

344 Normal Periodontium and Various Manifestations of Recession as Viewed in Orofacial Section Recession (blue), junctional epithelium (JE), minimal PD (red). The mucogingival line (arrowheads) and the CEJ are indicated. A Gingiva and normal bone B Simultaneous recession of bone and gingiva, fenestration C Bony dehiscence more pronounced than gingival recession D Recession with formation of McCall’s festoon (Fig. 350).

Skull Observations

345 Fenestration (left) Adjacent to the fenestration on tooth 13 (circle), dehiscences and horizontal bone loss in the interdental areas.
346 Dehiscence (right) A pronounced dehiscence thatextends almost to the apex is observed on the facial of 13. The other teeth exhibit dehiscences of lesser severity. Generalized interdental bone loss is also in evidence (right).

Findings During Surgery

347 Multiple Fenestrations During the course of an Edlan operation, large fenestrations on teeth 16, 15 13 and 12 became visible after flap reflection (left).
348 Dehiscence on Tooth 13 During an extension operation using FGG, an unexpected osseous dehiscence was encountered, which had not been detected by probing. The dehiscence was more severe than the orginal gingival recession (right).

Clinical Symptoms

  • Gingival recession (of the entire gingival margin)

  • Stillman cleft

  • McCall’s festoon

The clinical manifestations of recession are numerous. Gingival recession usually begins with a gradual apical migration of the entire facial aspect of the gingiva, revealing the CEJ. Less frequently, the first sign of recession is the relatively rapid formation of a small groove in the gingiva, a socalled Stillman cleft. This can expand into pronounced recession. As a consequence of recession, the remaining attached gingiva may become somewhat thickened and rolled, a noninflammatory fibrotic response known as McCall’s festoon (Fig. 350).

If the recession progresses to the mucogingival line, secondary inflammation of the gingival margin often occurs (Fig. 351).

Gingival recession can lead to esthetic considerations in the maxillary anterior segment. As root surfaces are exposed, cervical sensitivity may also become a problem. Gingival recession is often observed on teeth that exhibit wedge-shape defects at the cervical area (p. 164).

349 Initial Recession Early exposure of the cementoenamel junction (arrows) due to recession of the gingival margin. The mobile oral mucosa has been stained with Schiller iodine solution (see Fig. 363). Palatal Recession (left) Gingival recession on the palatal or lingual surfaces is considerably less common than on facial surfaces (morphology).
350 McCall’s Festoons The attached gingiva consists of nothing more than a collar-like, fibrous thickening (arrow). This may be a tissue response to further recession beyond the mucogingival line. Stillman Cleft (left) Cleft-like defect of traumatic etiology. Such clefts may spread laterally, creating an area of gingival recession. The exposed root surface may be extremely sensitive. Such clefts are often covered with plaque.
351 Severe Localized Recession The root of this tooth has been denuded all the way down to the mucogingival line. The gingival margin is secondarily inflamed. Following initial therapy, mucogingival surgery for covering the exposed root was indicated (Miller class II; p. 163). Dehiscence of the Alveolar Process (left) Orofacial section through an anterior tooth, as viewed in the radiograph. Remarkably little bone surrounds the tooth, facially and lingually.
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Jul 2, 2020 | Posted by in Dental Hygiene | Comments Off on Gingival Recession
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