Studying Gingival Recession Diagnosis and Treatment

American Academy of Periodontology (AAP) 2018 Classification of Periodontal and Peri-Implant Diseases and Conditions

  1. Periodontal Health, Gingival Diseases and Conditions

    • Periodontal Health and Gingival Health

    • Gingivitis: Dental Biofilm-Induced

    • Gingival Diseases: Non-Dental Biofilm-Induced

    • Periodontitis

      • Necrotizing Periodontal Diseases

      • Periodontitis as a Manifestation of Systemic Disease

      • Periodontal Abscesses and Endodontic-Periodontal Lesions

      • Periodontal Manifestations of Systemic Diseases and Developmental and Acquired Conditions

      • Systemic Diseases or Conditions Affecting Periodontal Supporting Tissues

    • Mucogingival Deformities and Conditions

      • Traumatic Occlusal Forces

      • Tooth- and Prosthesis-Related Factors

    • Peri-Implant Diseases and Conditions

      • Peri-Implant Health

      • Peri-Implant Mucositis

      • Peri-Implantitis

      • Peri-Implant Soft and Hard Tissue Deficiencies

Mucogingival Conditions Without Gingival Recession

Associated Features

  • Tooth position

  • Aberrant frenum

  • Vestibular depth

  • Mucogingival Deformities and Conditions around Teeth

    • Periodontal phenotype

    • Gingival/soft tissue recession

    • Lack of keratinized gingiva

    • Decreased vestibular depth

    • Aberrant frenum/muscle position

    • Gingival excess

    • Abnormal color

Periodontal Phenotype

  • Types:

    1. Thin-scalloped

    2. Thick-flat

    3. Thick-scalloped

  • Components: Combination of gingival thickness, keratinized tissue width, and bone morphotype.

Gingival Thickness Measurement

  • Color-Coded Biotype Probe System:

    • White: Thin (< 1 mm)

    • Green: Medium

    • Blue: Thick (> 1 mm)

Keratinized Tissue Width

Problems with Narrow Zone of Keratinized Tissue (KT)

  • Insufficient to protect against:

    • Injury during mastication

    • Pull of frenum (Friedman, 1957; Ochsenbein, 1960)

    • Subgingival plaque formation (Friedman, 1962)

    • Attachment loss and soft tissue recession (Stern, 1976; Ruben, 1979)

    • Oral hygiene measures (Gottsegen, 1954; Corn, 1962)

How Much Keratinized Tissue is Adequate?

  • According to various studies:

    • ≥ 1 mm KT (Bowers, 1963)

    • > 3 mm KT (Corn, 1962)

    • Sufficient KT must:

    1. Be compatible with health

    2. Prevent retraction of the gingival margin during movement of alveolar mucosa (Friedman, 1962)

    3. ≥ 2 mm KT; < 2 mm is associated with clinical signs of inflammation (Lang & Loe)

    • Resistance to recession is not necessarily linked to width of KT; a narrow zone of KT has a similar degree of resistance to recession (Dorfman et al, 1980).

Gingival Augmentation When No Recession Present

Indications

  • Discomfort during toothbrushing and/or chewing

  • Planned orthodontic tooth movement expected to induce alveolar bone dehiscence

  • Increased soft tissue thickness can mitigate the risk of recession.

Gingival Grafting Procedures

  1. Pedicle Grafts

    • Maintain connection to donor site after placement

  2. Free Grafts

    • Deprived of connection with donor site (Haggerty, 1966)

  3. Alternative Grafts:

    • Acellular Freeze-Dried Dermal Matrix (ADM) (Wei et al, 2000)

    • Human Fibroblast-Derived Dermal Substitute (McGuire & Nunn, 2005)

    • Porcine Collagen Matrixes (Sanz et al, 2009)

Free Soft Tissue Graft Technique

Steps:

  1. Preparation of Recipient Site: Sharp dissection creating a periosteal bed.

  2. Graft Harvesting: 1.5-2.0 mm thickness graft from palatal donor site, typically near premolars.

  3. Placement: Sutured, pressure applied for 5 min to ensure successful plasmatic circulation to the graft.

  4. Post-Op Care: Remove sutures in 1-2 weeks.

Healing of Free Soft Tissue Graft

Phases:

  1. 0-3 Days:

    • Grafted tissue survives with avascular plasmatic circulation from the recipient periosteal bed.

    • Epithelium will desquamate.

  2. 2-11 Days:

    • Revascularization occurs; anastomoses between recipient bed and graft vessels.

    • New capillary growth and graft re-epithelialization.

  3. 11-42 Days:

    • Tissue maturation and return to normal vascularity.

Mucogingival Condition with Gingival Recession

Associated Features

  • Interdental CAL

  • Gingival Phenotype

  • Root Surface Condition (NCCL, caries, restoration)

  • Detection of CEJ

  • Tooth Position

  • Aberrant Frenum

  • Number of Adjacent Recessions

Gingival Recession

  • Definition: Apical shift of gingival margin concerning the Clinical Evaluation of Junction (CEJ).

  • Association: Related to Clinical Attachment Loss (CAL) and root exposure (Cortellini & Bissada, 2018).

Risk Factors for Gingival Recession (Kim & Nieva, 2015)

  • Thin Periodontal Phenotype

  • Absence of Attached Gingiva

  • Thin Alveolar Bone

  • Abnormal Tooth Position in Arch

Contributing Factors to Gingival Recession

  • Toothbrush Trauma (Sangnes, 1976)

  • Plaque-Induced Inflammation (van Palenstein Helderman et al, 1998)

  • Alveolar Bone Dehiscence (Bernimoulin & Curilovic, 1977)

  • Frenum Pull (Trott & Love, 1966)

  • Iatrogenic Restorative Treatment (Lindhe & Nyman, 1980)

  • Subgingival Restorations + Plaque (Stetler & Bissada, 1987)

  • Orthodontic Treatment (labial movement, thin gingiva) (Kim & Nieva, 2015)

  • Destructive Periodontitis (Serino et al, 1994)

Orthodontic Consideration

  • Risk Factors: Thin periodontal phenotype and planned buccal/rotational tooth movement

  • Recommendation: Graft/root coverage prior to orthodontic treatment.

Diagnosis of Gingival Recession

Classification of Gingival Recession (Miller, 1985)

  • Class I: Marginal recession not extending to MGJ, no loss of interdental papilla or bone.

  • Class II: Marginal recession to or beyond MGJ, no loss of interdental papilla or bone.

  • Class III: Marginal recession to or beyond MGJ, with loss of interdental papilla/bone or tooth malposition.

  • Class IV: Marginal recession to or beyond MGJ, with severe loss of interdental papilla/bone or severe tooth malposition.

Root Coverage Possibility

  • Miller Class I & II: Complete root coverage achievable.

  • Miller Class III & IV: Partial root coverage possible.

Classification of Recession (Cairo et al, 2011)

  1. Recession Type 1 (RT1):

    • No loss of interproximal attachment.

    • Interproximal CEJ not detectable.

    • Equivalent to Miller Class I and II; predictability of 100% root coverage.

  2. Recession Type 2 (RT2):

    • Loss of interproximal attachment.

    • Interproximal CAL ≤ Buccal CAL; similarities to Miller Class III; potential for some root coverage.

  3. Recession Type 3 (RT3):

    • Loss of interproximal attachment.

    • Interproximal CAL > Buccal CAL; similar to Miller Class IV; total root coverage not achievable.

Further Classification (Cairo et al, 2011)

  • Class A: CEJ detectable

  • Class B: CEJ not detectable

  • Cervical Step: Presence or absence, defined as deeper than 0.5 mm.

Non-CariouS Cervical Lesions

  • Class A-: Identifiable CEJ without a step

  • Class A+: Identifiable CEJ with a step

  • Class B+: Unidentifiable CEJ with a step

  • Class B-: Unidentifiable CEJ without a step

Indications for Root Coverage Procedures

  • Esthetic and cosmetic demands

  • Root sensitivity issues

  • Facilitate plaque control

Untreated Gingival Recession Consequences

  • Long-term outcomes: Facial gingival recession likely to increase (Chambrone & Tatakis, 2016).

    • Sample Study: Treatment comparison of thin gingival phenotype over 18-35 years revealed increased recession in 48% of untreated sites and reduction in 83% of treated sites.

Root Coverage Procedures

  1. Pedicle Soft Tissue Graft +/- barrier membrane or Enamel Matrix Derivative.

  2. Lateral Sliding Flap

  3. Double-Papilla Flap

  4. Coronally Repositioned Flap

  5. Semi-Lunar Coronally Repositioned Flap

  6. Free Soft Tissue Graft along with pedicle graft or envelope/tunnel flap.

Factors in Selection of Surgical Techniques

  • Local anatomical characteristics

  • Number of recession defects needing treatment

  • Size of recession defect

  • Height and width of papilla

  • Height/thickness/color of KT apical and lateral to exposed root

  • Depth of vestibule

  • Presence of marginal frenuli

  • Patient requests

  • Surgeon preferences

Factors Affecting Degree of Root Coverage

  • Poor oral hygiene

  • Smoking habits

  • Toothbrush trauma

  • Level of interdental papilla

    • RT1-2: Complete root coverage possible

    • RT3: Partial root coverage

  • Width of recession defect (>3 mm): Less favorable for root coverage

  • Depth of recession defect (≥ 5 mm): Less favorable for root coverage

  • Non-caries cervical lesions (NCCL) reduce the probability of complete root coverage (Jepsen et al, 2018).

Root Preparation during Root Coverage Procedures

  • Scaling and Root Planing (SRP):

    • Reduces root prominence, removes shallow caries, restoration if possible.

  • Root Demineralization Agents:

    • 24% EDTA: To remove the smear layer and expose collagen fibrils in dentin for graft attachment.

    • Note: Evidence shows no significant improvement in clinical outcomes of root coverage (Oliveira & Muncinelli, 2012).

Coronally Advanced Flap (CAF)

  • A technique where gingival tissues and alveolar mucosa are moved coronally to the CEJ to cover the exposed root (Allen & Miller, 1989).

  • CAF Modifications (De Sanctis & Zucchelli, 2007): Mobilization of 1 mm coronal to CEJ; de-epithelialization of papilla for connective tissue bed.

Subepithelial Connective Tissue Graft + Pedicle Graft

  • Advantages: Less invasive palatal donor harvest; Provides more aesthetic outcomes than a free soft tissue graft (FSTG).

Tunnel Approach for CT Graft

  • Pouch Technique (Raetze, 1985): Split-thickness pouch to insert CT graft, adhere with cyanoacrylate, no sutures required.

  • Tunnel Technique (Allen, 1994): For treating multiple adjacent recessions via a coronally advanced tunnel covering graft.

Laterally Positioned Flap Technique

  • Grupe & Warren (1956): Modified by Staffileno (1964).

    • Involves two vertical oblique incisions and uses keratinized tissue from adjacent tooth (often distal tooth).

Treatment of Choice for Mandibular Posterior Teeth

  • Multiple Coronally Advanced Flap: (Zucchelli, 2009)

    • No vertical incisions due to proximity of Mental Nerve; utilizes oblique incisions for access.

Soft Tissue Substitutes for Gingival Recession Treatment

  • Acellular Dermal Matrix (ADM): Allograft derived from human skin, processed to remove cellular components; retains extracellular matrix for grafting.

  • Collagen Matrix: Porcine xenograft materials; provide soft tissue replacement options.

    • Comparable short-term results to native tissue with long-term stability yet to be confirmed.

Questions & Conclusion

  • Recap: The significance of diagnosing and treating gingival recession for oral health; implications of untreated conditions on aesthetic and functional outcomes.

  • Thank you for your attention!