Gingival recession

Presented by : Dr Eman Gsouma

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Causes &

classification

Case report Sugical treatment

Introduction

Conclusions

Outline

Non-surgical treatment

Introduction

• Gingival recession in its localized or generalized form of an undesirable condition resulting in root exposure where there is an apical shift in position of gingival margin from the CEJ occurring gradually .

* The recent surveys reported that 88% of 65 years old and 50 % of people between 18 to 64 years old have one or more sites with recession. (American dental association 2003 )

Symptoms and problems

• Sensitivity • Esthetic complains • Root caries • Teeth discoloration • Abrasion • Difficulty maintaining plaque control

Causes1- Anatomical2-Plaque induced periodontitis 3- Trauma

• Trauma (con᾿t)

• Iatrogenic factors

• Smoking and Tobacco products

• Aging was also thought to cause gum recession. However this idea was

discarded because of lack of convincing evidence that aging cause’s shift of gingival attachment .

• Hormonal changes

Hormonal changes in women during pregnancy, menstruation and lactation can cause gums to become more sensitive and become more vulnerable to recession.

• Gingival biotype.

Classification

Treatment

Non-surgicaL Surgical

1- free soft tissue graft a- Epithelia graft b- Subepithelial C.T graft

2- pedicle soft tissue flap a- rotational flap b- advancement flap

1. Monitoring and prevention2. Use of desensitising agents, varnishes3. Composite restoration 4. Removable gingival veneers 5. Orthodontics

Monitoring and prevention

If the recession is not progressing and does not provoke tooth sensitivity or poor aesthetics, then tooth-brushing instructions and regular observation through a strict maintenance program would be the optimal treatment.

Desensitising agents, varnishes

• Treatment of dentine hypersensitivity is based on blocking the dentinal tubules and preventing nerve stimulation .

Pro-Argin™ Technology contains arginine, an amino acid naturally found in saliva, and calcium carbonate .

Composite restorations

Use of composite resin to mask recession defects and eliminate black triangles caused by recession. Enameloplasty was carried out to even incisal plane in this case

Removable gingival veneers

Orthodontics

• In some cases surgical intervention and grafting may help to treat the recession defect; however, if orthodontic treatment is an option that the patient is willing to consider then any surgical intervention should be delayed until after orthodontic tooth movement has been completed.

Indications for surgical intervention

The need to improve soft tissue aesthetics Reduce hypersensitivity

Improve plaque control

Prevent further progression of recession defect

Factors affecting outcome of periodontal plastic surgery• Condition of root surface – presence of calculus, caries,

contaminated cementum or restorations on root surface • Prominent fraenal attachments • Depth of vestibule• Tissue type (Thickness of split thickness flaps raised )• Size of the recession defect and graft material • Smoking • Patient oral hygiene.

The Free Gingival Graft

1- The epithelialised free gingival graft can be used in either a one stage or two-stage procedure to cover the exposed root surface

• there needs to be adequate overlap of the graft tissue with the soft tissue around the recession defect at the recipient site.

• Immobilisation of the graft at the recipient site is also essential

Disadvantage : the epithelialised free gingival graft is that it retains the colour of the donor tissue

The Free Gingival Graft

2- Subepithelial connective tissue graft

The pedicle flap

Advancement flap

The pedicle flap

Lateral

The pedicle flap

Transpositional flap by PENNEL ET EL

The pedicle flap

Double papilla flap

Guided tissue regeneration

• The mean root coverage achieved with guided tissue regeneration has been shown to vary between 48-94%

The use of Allografts and Xenografts in management of gingival recession

• A recent systematic review concluded that these grafts may be useful in situations where

1- A large recession defect needs to be treated . 2- Graft tissue harvested from the palate would provide an

insufficient volume of tissue.

Prognosis

• The subepithelial connective tissue graft has been shown to provide a greater percentage root coverage than the epithelialised free gingival graft

• Subepithelial connective tissue graft combined with a coronally advanced flap has been shown to provide better root coverage than the coronally advanced flap alone over a five year follow up period

• When the subepithelial connective tissue graft is compared with guided tissue regeneration, the subepithelial graft has shown evidence of achieving greater root coverage

Criteria of successful root coverage

Case report 1

• A 21-year-old male was referred to the Periodontics Department, by his orthodontist because of severe gingival

recession of maxillary central incisors .

Orthodontic treatment was done with no sign of recession and during the retention phase using hawley appliance sever fast gingival recession occurred . The orthodontist had discontinued utilization of the appliance and had referred the patient .

Journal of Periodontology & Implant Dentistry Periodontol Implant Dent 2010; 2(2):83-87 Tehran, Iran

The clinical examination revealed these findings: • 1. Gingival recession on the labial aspect of both maxillary central incisors,

which extended apically to about one-half of the root length. • 2. The interdental gingiva of mesial and distal aspects of both central incisors

had relatively normal appearance and was at normal position. • 3. Both central incisors exhibited Class II mobility. • 4. There were deep periodontal pockets on distal surfaces of central incisors;

however, pocket depth was normal on their mesial surfaces. • 5. Oral hygiene was adequate.• 6. Both teeth responded to electric and thermal vitality tests. • 7. There was no gingival inflammation, periodontal pockets or bone loss in other areas of the mouth .

• Radiographic examination disclosed severe bone loss on the distal surfaces of central incisors, which ex-tended to the apical third of the roots, while bone height on the mesial surfaces appeared normal .

The occlusal evaluation showed no premature contacts in centric and eccentric relations .

However, after completion of the surgery and detecting the elastic band, the patient remembered that after completion of the orthodontic treatment he had been referred to a restorative dentist to close the residual maxillary diastema with composite resin restorative material.

But the dentist had used latex elastics to close the diastema for optimal esthetic results and then had restored the lateral incisors. The patient pointed out that the elastic band had been removed by the dentist, but it turned out that one of the elastics had slipped under the gingival margin without the dentist noticing it.

Subpedicle connective tissue graft” was selected

2 -Emdogain – for gingival recession treatment

Case by PD Dr. S. HägewaldAssistant professor at the University of Berlin .Berlucchi et al. J Periodontol. 2005;76:899–907.

Straumann® Emdogain leads to :an increased amount ofkeratinized tissue, improved soft tissue healing and reducedreoccurrence of the recession, making the use of the moreTraumatic connective tissue graft in many cases unnecessary

Conclusions

• Treatment of the gingival recession will depend on the patient complain in the first place .

• The subepithelial connective tissue graft with a cornonally advanced flap is gold standard grafting procedure .

• Prognosis (amount of root coverage achieved) will depend on the severity (size )of recession .

References

• American Dental Association Vol 134, No 2, 220-225. © 2003 The etiology and prevalence of gingival recession MOAWIA M. KASSAB, D.D.S., M.S. and ROBERT E. COHEN, D.D.S., Ph.D.

• British Dental Journal 211, 353 - 358 (2011) Published online: 21 October 2011 | doi:10.1038/sj.bdj.2011.861

• BRITISH DENTAL JOURNAL VOLUME 211 NO. 6 SEP 24 2011• Periodontal surgery ,a clinical atlas , Naechi Sato DDS Japan 2000• Treatment and Causes of Gum Recession . Dental hub. Leading dental consultation• Berlin/Germany .Spahr et al. J Periodontol. 2005;76:1871–1880. 4 Moses et al. J

Periodontol. 2006;77:195–202• Professional Education: Article Pro-Argin™ Technology Mode Of Action

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