Gingival Recession Overview

Gingival Recession

• Gingival recession is the displacement of the gingival margin apically to the cemento-enamel junction, leading to root surface exposure.

Intended Learning Outcomes

• Understand the various factors contributing to gingival recession, including aetiology (causes).
• Recognize the oral health impact on the dental patient due to recession.
• Learn methods for measuring and monitoring recession.
• Identify different treatment options for gingival recession.

Definition

• Gingival recession is the apical displacement of the gingival margin relative to the cemento-enamel junction, exposing the root surface.

Revision of Healthy Gingival Tissues

• Alveolar mucosa, mucogingival junction, attached gingiva, free gingiva, interdental papilla, and stippling are parts of healthy gingival tissue
• Free gingiva + Attached gingiva = Keratinized Tissue (KT)

Clinical Appearance

• Determine if gingival recession is localized or generalized.

Recession

• Usually, recession is confined to one aspect (labial or buccal) of a tooth.
• Recession doesn't automatically compromise periodontal support.
• Underlying causes of recession need to be considered.

Causative Factors of Gingival Recession

• Mechanical factors (e.g., toothbrush trauma, traumatic incisor relationship, trauma from foreign bodies, abnormal frenum attachment, iatrogenic damage)
• Inflammatory factors (e.g., gingival biotype, periodontal disease, smoking, poor marginal fit of restorations, orthodontic tooth movement).

Mechanical Factors

• Toothbrush trauma (aggressive brushing technique, inappropriate oral hygiene aids)
• Traumatic incisor relationship (lower incisors impacting the upper incisors)
• Trauma from foreign bodies (e.g., lip or tongue studs)
• Abnormal frenum attachment (apical pull on gingival tissues, hindering oral hygiene)
• Iatrogenic damage (damage during dental procedures)

Toothbrush Trauma

• Prolonged aggressive brushing technique is a major cause
• Often coupled with improper oral hygiene aids

Trauma from Foreign Bodies

• Examples include lower lip studs and tongue studs

Traumatic Incisal Relationship

• The bite is characterized by lower incisors impacting palatally against the upper incisors

Abnormal Frenum Attachments

• A pronounced frenum attachment can exert an apical pull on the gingival tissues, making oral hygiene difficult, and leading to localized periodontal issues and recession.

Iatrogenic Damage

• A known risk relating to successful periodontal treatment
• Patients should be cautioned about the effects of recession during periodontal treatments

Inflammatory Factors

• Gingival biotype (delicate, translucent tissue is more susceptible)
• Periodontal disease (apical migration of the gingival margin)
• Smoking (affects periodontal status, increasing susceptibility to periodontal disease)
• Poor marginal fit of restorations (low-grade irritant, subgingival margins)
• Orthodontic tooth movement (accelerated movement)

Gingival Biotype

• Delicate and almost translucent appearance.
• Minimal attached gingiva.
• Friable tissue.

Periodontal Disease

• Apical migration of the gingival margin is a common indicator.

Smoking

• Smoking has a detrimental impact on periodontal health and increases susceptibility to periodontal disease.

Poor Marginal Fit of Restorations

• Low-grade irritant from sub-gingival margins can impinge on the biologic width.
• Potential for plaque stagnation.
• Contributing factor for recession in susceptible patients.

Orthodontic Movement

• Tooth movement may cause gingival recession, especially in thin tissue biotypes during rapid orthodontic procedures in adults.

Impact of Gingival Recession on the Patient

• Dentine hypersensitivity
• Aesthetic concerns
• Root caries
• Food trapping
• Plaque stagnation
• Difficulty with comfort (e.g., eating)

Dentine Hypersensitivity

• Recession exposes dentine.
• Hyperaemia of pulp may also result.

Aesthetic Considerations

• Risk of poor aesthetics.
• Black triangles.

Root Caries

• Exposed root surface is less mineralised and more susceptible to caries than enamel

Plaque Stagnation and Food Trapping

• Poor oral hygiene can lead to food and plaque stagnation in recessed areas.
• Recommending appropriate oral hygiene aids is important.

Summary of Causative Factors

• Provide descriptions of each causative factor.
• Explain how they cause recession.
• Explain the consequences of recession and related risks

Measuring and Monitoring Recession

• Measure distance from the cemento-enamel junction (CEJ) to the gingival margin.
• Ensure the probe is held parallel to the long axis of the tooth.
• Use a probe with clear markings

Loss of Attachment (LOA)

• Combined effect of recession and probing depth.
• Sometimes referred to as clinical loss of attachment (CLOA) or clinical attachment loss (CAL).

Recession in the Patient

• Steps to identifying, monitoring, and treating recession:
• Refer patient.
• Inform patient
• Monitor.
• Identify underlying cause.
• Treat as needed.
• Measure and record the recession.
• Educate the patient.

Miller's Classification of Recession

• Different classifications based on extent of recession: Class I, II, III, IV
• Descriptions for each class include the location of recession relative to the mucogingival junction, and the loss (or absence of loss) of interdental bone or soft tissue.

Management of Gingival Recession

• Patient education
• Monitoring
• Reduction of habitual factors
• Periodontal stabilisation
• Do nothing and stabilize (treatments may be used)

Advice to Patient

• Tooth brushing technique coaching with appropriate oral hygiene aids.
• Recommending appropriate adjuncts for sensitivity (e.g., desensitizing agents).
• Habitual advice.

Treatment Modalities for Clinical Symptoms

• Periodontal treatment.
• Desensitizing agents.
• Gingival veneers.
• Composite restorations.
• Referral for surgical intervention

Gingival Veneer

• Removable acrylic facing that improves aesthetics for advanced/generalized recession cases.
• Case selection is crucial.

Restorations

• Composite restorations to protect exposed dentin (especially in cervical regions), which is sensitive and prone to caries.
• Case selection is crucial.

Gingival Graft Surgery

• Complex periodontal surgery procedure.
• Involves transplanting palatal gingival tissue to the affected site.

Monitoring Gingival Recession

• Record all recession points.
• Monitor and respond to treatment needs accordingly.
• Refer to specialist as necessary.

Summary Revision Slide

• Include a summary of gingival recession definitions.
• Discuss measurement of recession/loss of attachment (LOA).
• Include descriptions of all causative factors (mechanical and inflammatory).
• Discuss the impact on the patient.
• Discuss treatment modalities.

References

• The references provided are related to treatment recommendations, studies regarding gingival recession, along with other related topics in periodontics. Each reference is associated with a research study or publication supporting the study conclusions.