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Gingival recession: review and strategies in treatment of recession: 3 Case reports
Dr. Koppolu Pradeep*
Dr. Palaparthy Rajababu
Dr. Durvasula Satyanarayana
Dr. Vidya Sagar
*Dept of periodontics, Sri Sai College o f dental surgery, Vikarabad. [email protected]
Dept of periodontics, Kamineni institute of dental sciences, Narketpally.
Dept of periodontics, Kamineni institute of dental sciences, Narketpally.
Dept of periodontics, Kamineni institute of dental sciences, Narketpally.
Correspondence:
Dr .Pradeep.K
Dept of periodontics
Sri Sai College of dental surgery
Andhra Pradesh
India
Word count : 1665
Number of figures : 17
Running title : Strategies in treatment of gingival recession
One-sentence summary describing the key finding(s) .
mailto:[email protected]:[email protected]:[email protected] -
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The present report suggests that the selection of suitable procedure, specific and meticulous
surgical technique will provide successful and exceedingly predictable results in the management
of gingival recession.
Abstract
One of the most common esthetic concerns associated with the periodontal tissues is gingival
recession. Gingival recession is the exposure of root surfaces due to apical migration of the
gingival tissue margins; gingival margin migrates apical to the cementoenamel junction.
Although it rarely results in tooth loss, marginal tissue recession is associated with thermal and
tactile sensitivity, esthetic complaints, and a tendency toward root caries. This article reviews
etiology, consequences and the available surgical procedures for the coverage of exposed root
surfaces, including three case reports.
Key words: Recession, Cementoenamel Junction, Aesthetics, Graft
INTRODUCTION
Gingival recession is a problem affecting almost all middle and older aged to some degree.Gingival recession is the diagnosis if the gingival margin migrates apical to the cementoenameljunction (CEJ). The distance between the CEJ and gingival margin gives the level of recession.
Gingival recession can be caused by periodontal disease, accumulations, inflammation, improperflossing, aggressive tooth brushing, incorrect occlusal relationships, and dominant roots. These
can appear as localized or generalized gingival recession. Recession can occur with or withoutloss of attached tissue. Gingival recession may result in accentuated sensitivity because thedentin is exposed, it can be assessed by an appearance of a long clinical tooth and varied
proportion of the teeth relative to adjacent teeth.
PREVALENCE
According to the US National Survey, 88% of seniors (age 65 and over) and 50% of adults (18 to64) present recession in one or more sites; progressive increase in frequency and extent of
recession is observed with increase in age [1].
In the youngest age cohort (30 to 39 years), the prevalence of recession was 37.8% and the
extent averaged 8.6% teeth. In contrast, the oldest cohort, aged 80 to 90 years, had a prevalenceof 90.4% (more than twice as high) and the extent averaged 56.3% teeth (more than six times as
large) [2].
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Gingival recession is associated with the presence of supragingival and subgingival calculus andshowed that the lingual surfaces of the lower anterior teeth were most commonly affected in 20-
34 year age group in Tanzanian adult population [3].
ETIOLOGY
1) CalculusAssociation between gingival recession with supragingival and subgingival calculus canbe noted because of inadequate access to prophylactic dental care. [3]
2) Tooth brushingKhocht et al showed that use of hard tooth brush was associated with recession [4].
3)
High frenal attachmentThis may impede plaque removal by causing pull on the marginal gingival [5].
4) Position of the toothTooth which erupts close to mucogingival line may show localised gingival recession asthere may be very little or no keratinized tissue [6].
5) Tooth movement by orthodontic forcesThe movement of tooth such as excessive proclination of incisors and expansion of the
arch expansion are associated with greater risk of gingival recession [7].
6) Improperly designed partial denturesThe partial dentures which have been maintained or designed which cause the gingivaltrauma and aid in the plaque retention have the tendency to cause gingival recession [8].
7) SmokingThe people who smoke have more gingival recession than non smokers.
The recession sites were found buccal surfaces of maxillary molars premolars,mandibular central incisors and premolars [9].
8) RestorationsSubgingival restoration margins increase the plaque accumulation, gingival inflammation
and alveolar bone loss [10].
9) ChemicalsTopical cocaine application causes gingival ulcerat ions and erosions [11].
CONSEQUENCES
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1) AestheticsThe appearance of tooth becomes unattractive [16].
2)
Gingival bleeding and plaque retentionThe recession may be a site c linically which offers plaque retention.
3) HypersensitivityRecession will uncover the cervical dentine. Hypersensitivity is usually of a sharp andshort duration often associated with cold stimulus. The mechanism of hypersensitivity thatis accepted is the hydrodynamic theory of pain, which states that the movement of dental
fluid in the dentinal tubules triggers sensory nerve fibers in the inner dentine anddentinopulpal junction [17].
4)
CariesThere may be a risk of the development of root caries as root surfaces are exposed to oralenvironment and aid in the withholding of plaque. Patients on periodontal maintenance
with an average of 64.7 exposed root surfaces per patient, the mean number of carieslesions which were detected were 4.3 in a prevalence study [18].
TREATMENT
1) Restorations, crowns and veneersCrowns may be placed to widen the clinical crown which may camouflage the exposedroot surface
2) Construction of gingival maskPatients who have several teeth with recession may have unaesthetic appearance because
of black triangles. In these cases where surgical procedure is not appropriate siliconeflexible gingival veneer or mask may be used.
3) Root conditioningApplication of tetracycline HCL or citric acid to root surface before placement of soft
tissue graft.
4) FrenectomyWhen the recession is caused by frenal pull in those cases frenectomy is advised. Ifappropriate hygiene aids does not enable the patient to maintain the area plaque free then
frenectomy is advised to give ease to entrance to the site [19].
5) Surgical root coverage techniques
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Free epithelialised gingival graft [20].
Subepithelial connective tissue graft [21].
Semilunar flap [22].
Coronally advanced flap [23].
Guided tissue regeneration [GTR] [24].
Case report 1
A 43 old female patient complained of hypersensitivity inspite of using anti hypersensitivitypaste since 2 months and was also concerned about the esthetics. Patient had gingival recession
on the maxillary left canine and first premolar at the first examination (fig 1). The recessionmeasured 2 mm on the canine and 3 mm on the first premolar, respectively. The clinical
attachment loss was 4 mm from the CEJ for the canine and 5 mm for the first premolar,respectively. Oral prophylaxis has been done and oral hygiene instructions were given so as toachieve satisfactory plaque control prior to periodontal surgery. After reevaluation a Semilunar
incision and intracrevicular incisions have been given using Tarnow technique22 (fig 2). Theroots were planed with hand curettes to remove the flecks of the calculus and to obtain smooth
surfaces and then treated with tetracycline for 3 minutes (using a burnishing technique) (fig3).The root surfaces were then rinsed with saline. The flap was positioned as coronally as possible.The post operative healing after 2 months revealed an increase in 2mm of increase root coverage
was achieved (fig 5).
Fig 1 Facial view of gingival recession on 1st
premolar and canine. The patient complained of
root sensitivity in addition to the unaesthetic
appearance when smiling.
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Fig 2 Semilunar incision placed apically
Fig 3 Root conditioning with tetracycline
Fig 4 Coronally repositioned flap
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Case 2
A 31 old female patient complained of a black triangle in the upper front teeth region since 6months and was concerned about the esthetics and whistling sound while speaking (fig 6).
The interdental papilla between maxillary right central and lateral incisor was blunt (fig 6). Oralprophylaxis has been done and oral hygiene instructions were given so as to achieve satisfactoryplaque control prior to surgery. An intrasulcular incision is made at the tooth surfaces facing the
interdental area to be reconstructed(fig7), consequently an incision is placed across the facialaspect of the interdental area and an envelope-type, split-thickness flap is elevatedsimultaneously a Semilunar incision was given apical to the mucogingival junction and the flap
was coronally displaced using Langers technique. A connective tissue graft is harvested frompalate (fig8) and placed under the flap in interdental area (fig 9) and sutured back (fig 10). Fig
11 post operative healing after 6 months revealed the excellent closure of black triangle betweenthe left upper central and lateral incisors.
Fig 5 One -year postoperative view. Complete root
coverage is observed.
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Fig 6 Blunting of interdental papilla between
central and lateral incisor
Fig 7 Intrasulcular incision
Fig 8 Connective tissue graft taken from
palate
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Fig 9 Graft placement under the flap
Fig 10 Placement of suture
Fig 11 Closure of interdental papilla 6 months
Post operative
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Case 3
A 25 old female patient complained of hypersensitivity in the lower front teeth region since 2
months and was concerned about the esthetics. Patient had gingival recession on the mandibular
right central incisor at the first examination (fig 12). The clinical attachment loss was 5 mm fromthe CEJ. Oral prophylaxis has been done and oral hygiene instructions were given so as to
achieve satisfactory plaque control prior to periodontal surgery. The root surface was gently
scaled and planed; instrumentation was done by utilizing manual and power driven scalers and
curets. The shape of the root was not altered. The root surface was then treated with a
tetracycline 500 mg by attempting to burnish, with small cotton pledgets. The donor tissue was
removed from the palate and trimmed to a thickness of 2 to 3 mm (fig 15). Within minutes of
removal, the donor tissue was placed at the recipient site. Vertical stabilizing sutures (4-0 silk)
were used to secure the graft (fig 16). Post operative (fig 17) after 6 months.
Fig 12 recession of right central incisor
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Fig 13 Incisions for the removal of graft
Fig 14 Palate after removal of the graft
Fig 15 The donor tissue
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Discussion
The main goal of periodontal therapy is to improve periodontal health and thereby to maintain a
patients functional dentition right through his/her life. However, aesthetics symbolize aninseparable part of todays oral therapy, and numerous procedures have been proposed to
Fig 16 Suturing
Fig 17 Six months postoperative healing
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preserve or enhance patient aesthetics. This treatment has principally been justified by thepatients wish to advance the aesthetic appearance when there is an exposed root.
Etiology and the contributing factors are chief when deciding on appropriate treatment
procedures for patients with localized gingival recession. In the cases presented, the etiologies of
the gingival recession were scarce vestibular depth and inadequate width of keratinized gingiva.If malposition of teeth is supposed to be the etiology for recession then orthodontic t reatment
needs to be given a thought with or without periodontal therapy. Due to the existence of multiplemucogingival problems, it was decided to use a free gingival graft to accomplish root coverage
and to form functional attached gingiva. The band of keratinized tissue was determined to beadequate in all cases. The color match and the tissue contour were satisfactory to the patients inall cases mentioned above. In some cases the color match and tissue contour match were good
enough to make it complex to determine the position of the original defect.
The outcome of the current cases confirm aesthetics as the primary indication for root coverage.A recent survey showing that aesthetic concern was the foremost indication for root coverage
procedures.[25] Indications other than aesthetic, root sensitivity were low and were grouped inthe other category, accounting for 1.84% of the indications.
Conclusion
Gingival recession is one of the main esthetic complaints of patients. This also exposes patients
to sensitivity and greater risk for root caries. Mucogingival surgery strives to re-establish the
periodontium to a healthy functional state. Periodontal plastic surgery strives to restore the
periodontium to a healthy, e fficient, and aesthetic state. For coverage of exposed roots, there is a
vast range of mucogingival grafting procedures available in the present era. These procedures arequite predictable and produce satisfactory solutions to the problems presented by gingival
recessions. Choice of the suitable procedure, specific and thorough surgical technique will offer
successful and exceedingly predictable results in the management of gingival recessions.
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