Gingival Recessions
Definition
Gingival recession is defined as the displacement of marginal gingiva apical to the
cementoenamel junction (CEJ); thereby exposing the root surface to the oral environmentwhich
causes poor esthetic appearance and in some cases root hypersensitivity.The distance between
the CEJ and gingival margin gives the level of recession. It can occur in patients with good
standards of oral hygiene as well as those with poor oral hygiene and periodontal disease.
Recession may also be associated with cervical lesions such as abrasive class V cavities or root
caries.Gingival recession along with the inadequate width of attached gingiva and inadequate
vestibular depth are very common clinical finding in the front region of the lower jaw.
Prevalence of Recessions
The prevalence of gingival recession has been shown to increase with age.According to the US
National Survey, 88% of seniors (age 65 and over) and 50% of adults (18 to 64) present
recession in one or more sites; progressive increase in frequency and extent of recession is
observed with increase in age. In the younger age cohort (30 to 39 years), the prevalence of
recession was 37.8%.
Etiology of Recession
For decades, it was believed that gingival recession was a part of human aging processes;
however, there is not strong evidence supporting such a statement. Aging might increase the
possibility for the causes of gingival recession to act, but that does not mean they are inherent to
aging.
One of the main reason of gingival recession is resorption of underlying alveolar bone. Over
timein lack of support, normal or inflamed gingival soft tissues tend to keep up with cervical
bone levels; therefore, gingival recession is established.
The etiology of recessions is multifactorial. Factors are below; one or more factor may be
presented:
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Aggressive tooth brushing
Periodontal disease and periodontal treatment
Occlusal trauma
Iatrogenic damage
Aberrant frenal attachments
Aggressive tooth brushing.It is known that inappropriate daily brushing may physically wounds
gingival tissues. Traumatically using the toothbrush as well as other oral hygiene agents over
delicate gingival margins on a daily basis might gradually and slowly lead to gingival recession
over the years. In general, those cases are presented in combination with cervical wear as a result
of abrasion caused by the same agents.
Periodontal disease and periodontal treatment. Tissue destruction resulting from periodontal
disease encompasses gradual bone loss which might lead to apical gingival migration and root
exposure. At first, tissue loss is apparently compensated by gingival swelling. After periodontal
treatment swelling decreases and retraction of gingival tissue volume occurs. Thus, root will
become exposed to the oral environment, which esthetically, might be considered strange by the
patient, even though periodontal tissues are perfectly healthy at this point. Ideally patient should
be informed about this fact before periodontal treatment.
Occlusal trauma. Due to the increase in functional demand, alveolar bone resorption may occur.
In those cases, vertical bone loss is radiographically noticeable. On buccal surface, depending on
cortical plate thickness, vertical bone loss results in bone dehiscence over the affected root - a Vshaped cavity in the bone contour, thereby gingival bone support decreases. Gingival contour
will keep up with buccal bone contour, which results in V-shaped or angled gingival recession in
teeth affected by occlusal trauma and bone dehiscence. It should be once again highlighted that
this process is not associated with local dental plaque buildup and consequent chronic
inflammatory periodontal disease.
Iatrogenic damage caused by:
1. Restorative treatmentmay be a reason of recession. Restorative treatment, which involves
placement of subgingival margins of restorations, can directly impinge on the biologic width.
To re-establish the biologic width there may be some bone loss and apical migration of the
gingival tissues. Subgingival restoration margins increase the plaque accumulation, gingival
inflammation, and alveolar bone loss.Crowns, veneers and Class V restorations should have
enough prominence of vestibular contour to prevent trauma of gingiva by food, such trauma
also may cause recession.
2. Orthodontic treatment. Orthodontic tooth movement should not be considered as the primary
cause of gingival recession. Induced tooth movement does not cause any damage to gingival
tissues; however, during orthodontic treatment, the following might occur in a few patients.
In those cases, before gingival recession occurs, orthodontic movement had induced
dehiscence at the bone crest, as a result of moving a tooth towards an area with extremely
thin bone. Induced tooth movement should be carried out only at the alveolar bone trabeculae
space; however, during certain types of movement, teeth are also displaced at the expenses of
the outer cortical plate. In such cases dehiscence and fenestration may occur. The latter are
defects found in the outer cortical plate and act as "predisposing factors" of gingival
retraction. A potential means to avoid dehiscence and recession during orthodontic treatment
is to apply light, well-balanced forces to sets of teeth rather than to a single tooth. Movement
should be carefully planned
3. Aberrant frenal attachments have been mentioned as a cause of recession due to an apical
pull on the gingival tissues.Also high frenal attachments (close to the gingival margin) may
make oral hygiene difficult therefore leading to a localized periodontal problem and
subsequent recession.
Abberant frenal attachment
Short thick frenula of a lip in oral vestibule cause local trauma of soft tissues because of
mechanical pulling gingiva out from teeth and alveolar bone during speaking and chewing. It
cause ischemia of area of frenula attachment and may lead to encroach on the marginal gingiva,
pull the gingival sulcus, fostering plaque accumulation, bone resorption, gingival recessions and
diastema. These are actual also for buccal frenula.
Classification of Recessions
Various classifications have been proposed to classify gingival recession.
1. According to distribution:
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Localized
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Generalized or horizontal form is associated with chronic inflammatory destructive
periodontal disease. Loss of periodontal support in proximal areas results in apical
displacement of gingiva, including interdental papillae.
2. According to shape:
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V–shaped recession is associated with teeth subjected to occlusal trauma, especially in
patients with bruxism and clenching habits. In cases of severe apical migration, V-shaped
recession is known as Stillman's cleft. At the corresponding enamel, it is common to find
abfraction; while on the occlusal surface, wear facets caused by attrition are commonly
found, as being part of a lesion caused by occlusal trauma.
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U–shaped recession is generally associated with chronic inflammatory periodontal
disease, inadequate tooth brushing or inadequate frenulum insertion. U-shaped gingival
recession associated with inadequate traumatic brushing is surrounded by healthy gingiva
and is usually associated with abrasion, with a smooth, polished surface. There are cases
of U-shaped recession in which the area of root exposure is surrounded by a peripheral
festoon made up of swollen, inflamed gingival tissue resulting from local dental plaque
buildup. A few classical studies found in Periodontology literature refer to the
aforementioned condition as McCall's festoon.
3. According to loss of attached tissue:
 with loss of dentogingival junction and attached tissue (e.g. in case of periodontal
diseases)
 without loss of dentogingival junction and attached tissue (e.g. in case of occlusal
trauma)
4. One of the most widely followed classification is Miller's classification (proposed in 1985) of
gingival recession. Miller has primarily based his classification on following aspects:
 Extent of gingival recession defects
 Extent of hard and soft tissue loss in interdental areas surrounding the gingival recession
defects.
Miller’s classification is useful in predicting the final amount of root coverage following a
free gingival graft procedure.
Miller’s Classification of Recessions
Class I (Fig. 1): Recession does not extend to the mucogingival junction (MGJ). There is no
periodontal loss (bone or soft tissue) in the interdental area, and 100% root coverage can be
anticipated.
Figure 1. Recession Class I by Miller, MGJ – mucogingival junction
Class II (Fig. 2): Recession extends to or beyond the MGJ. There is no periodontal loss (bone or
soft tissue) in the interdental area, and 100% root coverage can be anticipated.
A
B
Figure 2. (A) Scheme of recessions Class II by Miller; (B) Clinical view of wide multiple
recessions Class II by Miller. MGJ – mucogingival junction
Class III (Fig. 3): Recession extends to or beyond the MGJ. Bone or soft tissue loss in the
interdental area is present or there is a malpositioning of the teeth, which prevents the attempting
of 100% of root coverage. Partial root coverage can be anticipated.
A
B
Figure 3. Scheme of recessions Class III by Miller: recession extends beyond the mucogingival
junction (MGJ), bone or soft tissue loss in the interdental area is present (A) or there is a
malpositioning of the teeth (B)
Class IV (Fig. 4): Recession extends to or beyond the MGJ. The bone or soft tissue loss in the
interdental area and/or malpositioning of teeth is so severe that root coverage cannot be
anticipated.
A
B
С
Figure 4. Gingival recessions class IV by Miller (A) scheme, MGJ – mucogingival junction;
(B)intraoral view of vestibular surfaces; (C)view of lingual surfaces of lower frontal teeth
Complaints
Patients tend to present with three main concerns, which are poor aesthetics, worry about
potential tooth loss and dentine hypersensitivity due to the exposed root surface following
gingival recession.
Clinical Features
The following clinical parameters should be taking to examine a recession at the mid-buccal
aspect of tooth with recession:
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Probing pocket depth (PD) was measured with a standard periodontal probe to the nearest
millimeter from the gingival margin to the bottom of sulcus
Clinical attachment level (CAL) was measured from the cemento-enamel junction (CEJ)
to the bottom of the sulcus
Recession depth (RD) measured from CEJ to the gingival margin
Recession width (RW) measured across the buccal surface at the CEJ level
The width of keratinized gingiva (WKG).
Gingival recession may be accompanied with cervical caries (Fig. 5), erosions, wedge-shaped
defects.
Figure 5. Recessions and cervical caries in teeth 13,14, before filling (left) and after filling
(right)
Treatment of Gingival Recessions
First aim for treatment of recessions is to reveal and to remove etiological factors to control
progression.Recessions do not require treatment if:
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they are not large and do not progress
esthetic concerns not a problem for patient
hypersensetivity of exposed roots is controlled with desensitizers or absent
There are surgical and non-surgical methods for recession treatment.
1.Non-surgical methods:
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Crowns, veneers, restoration. Crowns may be placed to widen the clinical crown which
may camouflage the exposed root surface
Construction of gingival mask. Patients who have several teeth with recession may have
unaesthetic appearance because of black triangles. In these cases, where surgical
procedure is not appropriate, silicone flexible gingival veneer or mask may be used.
Application of desensitizers on exposed roots.
2. Surgical methods. Surgical methods of recession treatment are among of mucogingival
surgery procedures. Aim of surgical methods is to close exposed root surface with either graft or
flap to repair esthetic and decrease root hypersensitivity.
Mucogingival Surgery
Terminology and Definition
The term mucogingival surgery was initially introduced in the literature by Friedman (1957). It is
applied to surgical procedures utilized to resolve problems involving the interrelationship
between gingiva and alveolar mucosa with reference to next problems:
 increasing of width and thickness of attached gingiva
 gingival recessions
 shallow vestibule
 aberrant frenal attachment.
This term is distinguished from periodontal surgery wherein alveolar mucosa is not handle.
With the advancement of periodontal surgical techniques, the scope of non-pocket surgical
procedures has increased, now encompassing a multitude of areas that were not addressed in the
past. Recognizing this, the 1996 World Workshop in Clinical Periodontics renamed
mucogingival surgery as periodontal plastic surgery, a term originally proposed by Miller in
1993. Periodontal plastic surgery is defined as the surgical procedures performed to correct or
eliminate anatomic, developmental, or traumatic deformities of the gingiva or alveolar mucosa.
Several surgical techniques have been developed for the management of shallow vestibule,
gingival recession, the inadequate width of attached gingiva and aberrant frenal attachment
which set out mucogingival problems.
Mucogingival Surgery Procedures
There are many modifications of mucogingival surgical procedures; the basic procedures are:
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Free gingival graft
Connective tissue graft
Coronally advanced flap
Pedicle flap
Deepen of vestibule
Frenectomy
Guided tissue regeneration for root coverage
Preparation of the exposed root surface. Before any surgical technique root surfaces are
mechanically prepared prior to any mucogingival procedure to allow biological attachment of the
grafted tissue to it. The root surface is thoroughly debrided and irrigated with sterile saline. At
the day of surgery the site should presented a healthy periodontium with the gingiva exhibiting
no evidence of bleeding on probing.
If the plan is to obtain root coverage over existing caries or class V restoration, the caries and
restoration must be completely removed (gingiva will not attach to artificial restorative material).
Significant convexity of the root may be reduced with diamond burs on high speed.Historically,
chemical root surface modifiers such as citric acid, tetracycline, or EDTA had been used to
demineralize and decontaminate the root surface to expose the collagen fibers. The theory is this
will facilitate attachment of gingival fibers to the root surface. However, recent evidence
demonstrates that the use of these chemical modifiers provides no benefit of clinical
significance.
Postoperative care are the same for all types of mucogingival surgical procedures. Immediately
following surgery, use of icepacks was recommended intermittently for three hours. The patient
is advised not to brush the treated site for 2 weeks. After 1 week toothbrushing of treated site
should be carried out gently with ultrasoft toothbrush. 0.12% chlorhexidine mouth rinse is
prescribed twice a day for 2 weeks. Systemic antibiotics were prescribed (Amoxicillin-500 mg,
three times daily for five days) along with analgesics. Sutures should be removed 7-10 days after
surgery. Patient should be examined weekly for the 1st month.
Free Gingival Graft
Free gingival graft is soft tissue graft comprising epithelium and thin layer of underlying
connective tissue that are completely detached from one site (donor site) and transferred to a
remote site (recipient site). Most common donor site for free gingival graft is hard palate. The
palatal masticatory mucosa is widely used as a connective tissue donor site in gingival recession
treatment. However, concern has been raised regarding the potential risk of damaging the greater
palatine artery during harvesting of graft due to anatomical variations in the palatal vault.
This technique allows:
1. To increase the zone of attached gingiva
2. To augment the thickness of attached gingiva
3. To repair gingival recession
Free gingival graft technique:
1. Preparation of the recipient bed.The recipient site should beprepared as split-thickness flap
(periosteum should not be detached from bone) and extend at least 3 mm laterally and apically to
the recession defect, as this will be the only nutrient supply to the graft during the initial healing
phase. Any muscle or frenal insertions should be removed by sharp dissection to ensure that the
graft lies passively with no movement occurring during function.
2. Harvesting of the graft. Graft should be harvested from donor site and the size should be
adapted. Proper thickness 1.0–1.5 mm is an important factor for survival of the graft because
nutrition of graft first time after surgery will be due to diffusion of nutrients from the recipient
site. If graft is too thick, central part will not have enough nutrition and will become necrotic.
Good adaptation of the graft to the recipient site is essential for adequate diffusion, so care must
be taken on preparing the recipient site the graft to the exact same size to ensure a good fit.
3. Transfer and suturing of the graft.Graft is applied on recipient site, sutured into position and
pressed by finger for several minutes for better adaptation.
Connective Tissue Graft
The connective tissue autograft technique was originally described by Edel and is based on the
fact that the connective tissue carries the genetic message for the overlying epithelium to become
keratinized.Therefore only connective tissue from beneath a keratinized zone can be used as a
graft. The Connective Tissue Graft (CTG) technique is considered as the gold standard in the
management of recession defects. It is also used in combination with coronally advanced flap.
Terminology: connective tissue graft = free connective tissue graft = subepithelial connective
tissue graft.
The free connective tissue graft (CTG) is differ with the free gingival graft is that the donor
tissue is connective tissue only with no epithelium on it. Donor site may be hard palate, tuber of
maxilla, retromolar region.
Advantages:
 double blood supply of graft at the recipient site from the underlying connective tissue
base and the overlying recipient flap.
 donor site is a closed wound, which produces less postoperative discomfort
 excellent color blend can be achieved
 Minimal palatal denudation, less invasive, less prone to hemorrhage, more rapid healing.
 The connective tissue graft results in two sutured closed wound sites, while the free
gingival graft results in two open exposed wounds.
Free connective tissue graft technique:
1. Preparation of the recipient bed. The recipient bed is prepared to accommodate the connective
tissue graft. Divergent vertical incisions are made at the line angles of the tooth to be covered. A
split thickness flap is performed where the periosteum remains attached to the underlyingbone.
The split thickness flap is prepared by sharp dissection and the presence of any muscle fibers or
attachment is eliminated. The flap should be mobile so that it can be repositioned to at least 5
mm apical to the receded area.Suture the apical mucosal border to the periosteum using a gut
suture.
2. Harvesting of the graft.The connective tissue graft is harvested from the hard palate. The ideal
location is 5–6 mm apical to the gingival margin of the palatal aspects of the maxillary premolars
and the mesial half of the maxillary first molar. The ideal thickness of the graft should be 1–1.5
mm thick. The donor site is sutured after the graft is removed.During harvesting the connective
tissue, the vital structure that needs to be avoided is the greater palatine artery. Depending on the
depth of the palatal vault, typically, the artery is about 12 mm apical to the gingival margin.
3. Transfer and suturingof the graft.The harvested connective tissue graft is immediately placed
in the recipient site and secure into position with sutures to the periosteum. Good stability of the
graft must be attained with adequate sutures. Optimized healing requires the graft to be in
intimate contact with the recipient bed with the absence of any dead space.
6. Covering of the graft. Cover the grafted site with dry aluminum foil and periodontal dressing.
Coronal Advanced Flap
The coronally advanced flap is commonly used to treat the Miller Classes I and II recession
defects.Various modifications of the coronally advanced flap (CAF) have been proposed with the
attempt of treating gingival recession.
Coronal advanced flap technique:
1. Horizontal and vertical incisions. Make a horizontal internal bevel incision from the gingival
margin to the bottom of the pocket to eliminate the diseased pocket wall. It is made at the
recession and extended with two vertical releasing incision in correspondence to the line angles.
Vertical incisions should go beyond the mucogingival junction.
2. Management of papilla. The interdental papilla is preserved as much as possible. Their facial
portion is deepithelialized to create a connective tissue bed.
3. Flap elevation. Full thickness flap is elevated. Horizontal incision in periosteum is placed at
the base of the flap to ensure tension free coronal displacement of the flap.
4. Flap repositioning. The flap is then coronally positioned to completely cover the defect and
secured using continuous sling suture.
5. Suturing of vertical incisions. Vertical releasing incisions are secured using interrupted suture
technique.
Pedicle Flap
There are many variations of pedicle flap, one of them laterally displaced pedicle flap. The
laterally positioned flap can be used to cover isolated, denuded root surfaces that have adequate
donor tissue laterally, adjacent to the gingival recession.
Laterally displaced pedicle flap technique
1. Preparation of the recipient site. Epithelium is removed around the denuded root surface. The
exposed connective tissue will be the recipient site for the laterally displaced flap. The root
surface will be thoroughly scaled and root planed.
2. Preparation of the flap. The periodontium of the donor site should have a satisfactory width of
attached gingiva and minimal loss of bone, without dehiscence or fenestration. A partialthickness flap is used. Prepare vertical incision from the gingival margin to outline a flap
adjacent to the recipient site. Extend the incision into the oral mucosa to the level of the base of
the recipient site. The flap should be sufficiently wider than the recipient site to cover the root
and provide a broad margin for attachment to the connective tissue border around the root.
Separate a flap consisting of epithelium and a thin layer of connective tissue, leaving the
periosteum on the bone. A releasing incision is sometimes needed to avoid tension on the base of
the flap,
3.Transfer the flap. Slide the flap laterally onto the adjacent root, making sure that it lies flat and
firm without excess tension on the base.
4. Suturing of a flap.Fix the flap to the adjacent gingiva and alveolar mucosa with interrupted
sutures.
Deepen the Vestibule
Among mucogingival problems, shallow vestibule and gingival recessions which cause an
esthetic as well as a functional problem are very common finding in lower front teeth. The
presence of adequate vestibular depth is important for both oral hygiene and retention of
prosthetic appliances. Numerous surgical techniques have been proposed to accomplish the
objective of deepening the vestibule. The aim of this vestibular extension procedure is to
increase the depth of vestibule and the width of attached gingival in a single visit.
Predictable deepening of the vestibule can only be accomplished by the use of free autogenous
graft techniques and their variants. The important clinical aspect in deepening the vestibule is the
proper preparation of the recipient site. The recipient site must be covered by immobile
periosteal tissue. The donor tissue may be either free gingival or connective tissue, but it must be
placed over a nonmobile recipient site. Clinical view of procedure is presented on figure 6.
А
C
B
D
Figure 6. Deepen the vestibule. (A) shallow vestibule of oral cavity and recessions; (B) incision
(C) cutting of muscle and connective tissue strands; (D) clinical view after healing
Frenectomy
When the recession is caused by frenal pull in those cases, frenectomy is advised. If appropriate
hygiene aids do not enable the patient to maintain the area plaque free, then frenectomy is
advised to give ease to entrance to the site. Indication to frenectomy: when place a probe to the
lowest part of free gingival grooves of central incisors, frenum attachment should be lower than
this line showing with the probe. If frenum attachment is above probe line – frenectomy is
indicated (Fig. 7). This rule is actual for both upper and lower jaw, but in upper jaw normal
frenum attachment should be above probe line.
Figure 7. Frenum attachment is a little bit higher than probe line.
Guided Tissue Regeneration Technique for Root Coverage
Guided tissue regeneration (GTR) should result in reconstruction of the attachment apparatus,
along with coverage of the denuded root surface.
Guided tissue regeneration technique for root coverage:
1. A full-thickness flap is reflected to the mucogingival junction, continuing as a partialthickness flap 8 mm apical to the mucogingival junction.
2. A resorable membrane is placed over the denuded root surface and the adjacent tissue. It is
trimmed and adapted to the root surface and covers at least 2 mm of marginal periosteum.
3. A suture is passed through the portion of the membrane that will cover the bone.
4. The flap is then positioned coronally and sutured.