gingival recession. part 1. nonsurgical management

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Gingival recession: part 1.Aetiology and non-surgicalmanagementM. Patel,1 P. J. Nixon2 and M. F. W.-Y. Chan3

VERIFIABLE CPD PAPER

teeth or a group o teeth and will have

wedge shaped deects with minimal

interproximal recession. For the major-

ity o people the area o recession is

more commonly associated with the

let side o their mouth. This relates

directly to the act most people are

right handed and brush the let side o

their mouth rst, when they are mosteective.1 The gingival tissues oten

appear to be healthy around the area o

recession and the exposed root surace

is smooth, clean and polished. Buccal

abrasion cavities may also be ound

with the area o recession

b. Traumatic incisal relationship can

cause striping o the gingival tissues.

Akerly 4 described our incisal relation-

ships and their eect on the sot and

hard tissues (Table 1). Akerly Class II

and III highlight that a traumatic ClassII Div 1 or Class II Div 2 incisal rela-

tionships can cause localised recession

o the upper anterior teeth palatally

and/or lower anterior teeth labially

GINGIVAL RECESSION

Gingival recession is the displacement

o the gingival sot tissue margin apical

to the cemento-enamel junction which

results in exposure o the root surace.1

The prevalence o gingival recession has

been shown to increase with age and can

occur in patients with good standards o

oral hygiene as well as those with poor oral

hygiene and periodontal disease.2

AETIOLOGY

Gingival recession occurs either due to a

direct mechanical or physical infuence on

the gingival tissues or indirectly due to an

infammatory reaction in the gingival tissues.

Mechanical/physical actors

These include aetiological actors which

cause direct apical migration o the gingi-

val tissues. These are:

a. Vigorous tooth brushing or by brush-

ing with a hard bristle toothbrush are

common causes o recession and this

is oten seen in patents with good oral

hygiene.1-3 It usually presents as local-

ised areas o recession mainly aect-

ing the buccal suraces o individual

Gingival recession is a common nding in many patients. Some patients will not be concerned whereas others will have

aesthetic concerns or complain o sensitivity. This paper highlights the aetiology o gingival recession, the treatment op-

tions available to treat any associated sensitivity and the non-surgical treatment options available to restore aesthetics in

patients with gingival recession. Subsequent papers in this series discuss the surgical treatment options available to correct

localised recession deects.

c. Trauma rom oreign bodies such as

lower lip piercings may also cause

recession.5 Similarly, poorly designed

tissue borne partial dentures can also

result in gingival stripping leaving a

recession deect

d. Teeth which are prominent and out o

alignment o the arch maybe associatedwith alveolar dehiscence which can

result in recession especially i there is

thin gingival biotype (Fig. 1) overlying

the dehiscence1,3,6

1*Specialist Registrar in Restorative Dentistry,2,3Consultants in Restorative Dentistry, Departmento Restorative Dentistry, Leeds Dental Institute,Clarendon Way, Leeds, LS2 9LU

*Correspondence to: Dr Mital PatelEmail: [email protected]

Refereed PaperAccepted 21 July 2011DOI: 10.1038/sj.bdj.2011.764©British Dental Journal 2011; 211: 251-254

• Direct mechanical/physical infuenceor indirect actors resulting in gingivalinfammation are key aetiological actorsin gingival recession.

• Treatment may only be necessaryor those patients presenting withan aesthetic concern or dentinehypersensitivity.

• Several surgical and non-surgicaltreatment options are available.

I N B R I E F

P R A C T I C

E

Fig. 1 Example o thin gingival biotype andrecession associated with bone dehiscence

Table 1 Akerly classication o traumatic incisal relationships

Class Description

I Mandibular incisors impinge on the palatal mucosa

IIMandibular incisors impinge on the palatal gingival margin o the maxillary incisors. Commonin Class II Div 1 relationships

IIIMandibular incisors impinge on the palatal gingival margin o the maxillary teeth and themaxillary incisors impinge on the labial gingival margin o the mandibular incisors. Common inClass II Div 2 incisal relationship

IV Associated with the wear acets developing on the palatal surace o the maxillary incisors and/or labial suraces o the mandibular teeth

BRITISH DENTAL JOURNAL VOLUME 211 NO. 6 SEP 24 2011 251



PRACTICE

e. Aberrant raenal attachments have been

mentioned as a cause o recession due

to an apical pull on the gingival tis-

sues, however, the evidence or this is

poor.1,6 High raenal attachments (close

to the gingival margin) may make oral

hygiene dicult thereore leading to a

localised periodontal problem and sub-

sequent recession (Figs 2a and 2b)

. Recession can oten occur as a result

o any iatrogenic damage caused by

restorative or periodontal treatment the

patient may have. Restorative treatment

which involves placement o subgingi-

val margins o restorations can directly

impinge on the biologic width. To re-

establish the biologic width there may

be some bone loss and apical migrationo the gingival tissues.2

Successul treatment o periodontal dis-

ease and gingivitis will also result in the

apical movement o the gingival margin.

In some cases where there are shallow peri-

odontal pockets, repeated root planing can

also result in resorption o the crestal bone

and gingival recession.1

Gingival recession caused

by an infammatory processThere are various predisposing actors which

can result in recession due to infammation

o the gingival tissues. These include:

a. Gingival biotype. The height o kerati-

nised tissue is not an important ac-

tor in predicting recession; however,

evidence shows the thickness o the

keratinised tissue is an important

prognostic actor. Subgingival plaque

results in presence o infammation

around the gingival margin. This area

o infammation rarely extends more

than 1-2 mm apically and laterally

thereore where the ree gingival tissue

is thick only a small area o connective

tissue is aected. However, where the

ree gingival tissue is thin and delicate

or in an area o alveolar dehiscence the

entire connective tissue can be aected

resulting in recession.2 Figure 1 shows

an example o thin gingival biotype

and Figure 3 shows an example o

thick gingival biotypeb. Periodontal disease is another com-

mon cause o recession which results in

the loss o the supporting bone around

a tooth.1 Usually a tooth aected by

periodontal disease will lose bone sup-

port around the tooth through an infam-

matory reaction which results in apical

migration o the sot tissue margin. These

patients are likely to show generalised

signs o recession on all suraces o the

teeth (interproximal, buccal and lingual/

palatal),2 although there are exceptions

c. Poor marginal t, inadequate crown

emergence angles, rough restoration

suraces and overhangs on restora-

tions can result in a plaque trap. This

can cause gingival infammation i the

patient is not meticulous with their

oral hygiene and subsequently lead to

recession o the gingival tissues2

d. Orthodontic tooth movement per se

will not cause recession; however,orthodontic movement o teeth labi-

ally outside the envelope o alveolar

bone will result in loss o buccal bone

(alveolar dehiscence) and a decrease in

gingival tissue thickness due to stretch-

ing o the gingival tissue bres.1,2 The

decreased thickness o gingival tissue

mimics a thin gingival biotype which

as discussed above is more prone to

recession rom plaque induced infam-

mation or even tooth brushing trauma.

I a tooth is moved lingually or pala-

tally within the envelope o the alve-

olar process, there is reduced risk o

recession deects developing as there is

no pressure and stretching o the labial

gingival tissue and thereore it main-

tains its protective unction against

plaque induced infammation.

PATIENT COMPLAINTS/CONCERNS

Gingival recession is a common eature

seen in many patients. Some patients will

be unaware o the condition, others will

be aware o it but not concerned about it

whereas some will be concerned about it

and will want it corrected. 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 surace ollowing

gingival recession.7 Recession may also

be associated with cervical lesions such

as abrasive class V cavities or root caries.

GINGIVAL AESTHETICS

In order to treat recession and address the

patient’s aesthetic concerns it is impor-

tant to have an understanding o gingival

aesthetics and the lip line. When consid-

ering aesthetics we must rst assess the

patient’s lip line. This should be done at

rest, while the patient is talking and when

the patient smiles to show the highest level

o the lip line. The key eatures to note

are the symmetry in the smile, the amount

o tooth tissue visible and the amount o

gingival show. Once an extra oral assess-

ment o the aesthetics has been completed

then a closer look at the oral tissues can be

carried out. This involves initially looking

at the teeth to see which teeth are present,

their position in the arch and the symme-

try between the two sides, ollowed by an

assessment o the gingival tissues.

In the dental literature several authors

have described the ideal position o the gin-

gival zenith (the highest point o the gingi-

val margin around a tooth) relative to the

vertical midline o the tooth.8-10 Chu et al .10

carried out a study looking at 20 healthy

patients with the average age o 27.7 yearsand ound that on average the gingival

zenith is 1 mm distal to the midline on the

central incisors, 0.4 mm distal to the mid-

line on the lateral incisors and the canine

Figs 2a-b Examples o localised recession

associated with high raenal attachment

a

b

Fig. 3 Example o thick gingival biotypewhich is least prone to recession

252 BRITISH DENTAL JOURNAL VOLUME 211 NO. 6 SEP 24 2011



PRACTICE

had no deviation rom the midline. Other

authors have suggested that the zenith o

the central incisor is as described above;

the lateral incisors have the zenith along

the midline and the canines slightly distal

to the midline.9,11 In reality the true position

o the zenith may not be important as long

as there is symmetry. It is important or us

to understand these aesthetic dimensions

when assessing the patient’s aesthetics, the

amount o recession and or planning treat-

ment to correct the recession.

TREATMENT

The aim o the treatment or gingival

recession should be to address the patient’s

concerns o sensitivity and/or aesthetics.

The treatment options available include:

1. Monitoring and prevention

2. Use o desensitising agents, varnishes

and dentine bonding agents

3. Composite restoration

4. Pink porcelain or composite

5. Removable gingival veneers

6. Orthodontics

7. Surgery.

NON-SURGICALTREATMENT OPTIONS

1. Monitoring and prevention

o urther recession

I the recession deect is minimal, not in

the aesthetic zone and there is no associ-

ated dentine hypersensitivity or root caries

it may be acceptable to the patient to do

nothing. In these cases it is important to

identiy and manage the cause o recession

such as tooth brushing trauma or chronic

periodontal disease to prevent urther

recession. It is also important to main-

tain good oral hygiene to prevent urther

plaque induced infammation which can

result in urther recession especially in thin

gingival biotypes.

In cases where the patient has a high

smile line and the gingival zeniths are une-

ven due to recession or where root caries

or dentine hypersensitivity develops the

patient may seek treatment.

2. Desensitising agents, varnishesand dentine bonding agents totreat dentine hypersensitivity

I the patient’s main complaint is sensitiv-

ity and aesthetics are not a concern, then

concentrating eorts to treat the sensitiv-

ity alone may be enough. Patients su-

ering rom dentine hypersensitivity may

avoid brushing areas which are sensitive

which can result in accumulation o plaque

and urther plaque induced recession. It

is thereore important to treat sensitiv-

ity. Treatment o dentine hypersensitivity

is based on either blocking the dentinal

tubules or preventing nerve stimulation.

There are many products available which

aim to cover the root surace and block

the dentinal tubules to prevent fuid move-

ment. Examples o these products include

varnishes, dentine bonding agents, glass

ionomer cements or composite resins. The

more resistant the product is to its removal

o the root surace, the better it will be

at treating sensitivity. Toothpastes and

mouthwashes are also widely available in

the market to help treat sensitivity. Some

products containing either strontium or

potassium aim to stabilise the nerve by

decreasing the nerve excitability. However,

a recent systematic review has suggested

that the evidence or this is weak.12 Other

products available contain silica and oxa-

lates which aim to occlude the dentinal

tubules. The literature on treatment o den-

tine hypersensitivity does not show one

treatment modality being better than the

others. I toothpastes are used, there may be some benet in smearing the tooth-

paste over the exposed root surace and

leaving it or approximately 30 minutes

beore brushing or rinsing it away. This

would leave the active agents within the

toothpaste in contact with the root sur-

ace or longer giving them more o a

chance at reducing the sensitivity. More

recently lasers have also been advocated

or the treatment o dentine hypersensitiv-

ity. They are thought to cause coagulation

o proteins in the dentinal tubules which

decreases permeability and allows devel-

opment o an amorphous sealed layer o

dentine caused by meltdown o the surace

but there is a lack o long term evidence

or this.13,14

3. Composite restorations

With the advancement in composite resin

materials and dentine bonding tech-

niques, adhesive composite restorationsare becoming more and more popular and

predictable in restorative dentistry. Small

localised recession deects with sensitiv-

ity, wear or caries o the root surace can

be corrected by bonding tooth coloured

composite over the exposed root surace.

This will result in a longer clinical crown

height which would be acceptable i the

patient has a low lip line or i adjacent

teeth can be treated in the same way to

maintain symmetry. On some occasions

it may also be possible to use composite

to treat more extensive recession deects

where there has been interproximal bone

loss oten seen in patients with periodontal

disease. The composite can be used to close

the black triangles and cover the exposed

root suraces associated with the reces-

sion deect (Figs 4a-b). Careul placement

o the composite restoration is essential to

ensure there are no plaque retentive mar-

gins which would promote urther gingi-

val recession. In some cases using tooth

coloured composite in this way may not

be aesthetically acceptable and alternative

options would need to be considered to

restore the aesthetics.

4. Pink porcelain or composite

Surgical procedures have been widely

described to successully treat recession

deects; however, in some patients surgery

may not be a viable option or an option

they wish to pursue. With advances in

bonding agents and the development o pink ceramics and resin composite materi-

als, it is possible to use gingival coloured

porcelain or composites over the root sur-

ace to eliminate dentine hypersensitivity

Figs 4a-b Use o composite resin to mask

recession deects and eliminate blacktriangles caused by recession. Enameloplastywas carried out to even incisal plane

a

b

BRITISH DENTAL JOURNAL VOLUME 211 NO. 6 SEP 24 2011 253



PRACTICE

and restore aesthetics.7 However, there

are some diiculties associated with

these techniques such as getting a good

colour match o the restorative material

with the gingival tissues, moisture con-

trol rom the gingival crevicular fuid

and ensuring there are no ledges as it

can make oral hygiene dicult leading to

urther recession.

5. Removable gingival veneers

Some patients will have multiple sites o

recession in the anterior aesthetic zone

which is most commonly associated with

periodontal disease. This results in exposed

root suraces and appearance o spacing

between the teeth where the dental papillae

have been lost, oten reerred to as ‘black triangles’. Some patients will also com-

plain o altered speech due to air escaping

through the recession deects interproxi-

maly. In these patients surgical techniques

to grat multiple sites to replace lost tissue

may be impossible and unpredictable.

The use o a removable gingival pros-

thesis can replace large volumes o receded

sot tissue, ll the interproximal spaces to

eliminate the black triangles and improve

aesthetics (Figs 5a-c). Removable gingi-

val prostheses can be made rom various

materials which include heat cured acrylic

or silicone based sot lining materials such

as molloplast B.15,16 A study by Lai et al .17

showed that gingival veneers made rom

heat cured acrylic had more colour stabil-

ity compared to silicone or co-polyamide

materials which were prone to staining rom

tea and coee. On the other hand acrylic

materials have the disadvantage o being

hard, ridged, easy to racture and dicult

to t around teeth. In comparison silicone

base materials are fexible, have improved

comort and increased resistance to racture.

The gingival prosthesis is made rom

a two part impression taken in silicone

(Fig. 6). Silicone putty is initially placed

on the palatal aspect ensuring it does not

go past the maximum curvature o the

teeth within the interproximal spaces. A

separating medium such as petroleum

jelly is placed on the palatal impression

once set and re-seated in the mouth. The

labial portion o the impression can thenbe taken with a heavy or medium bodied

silicone using a special custom made buc-

cal impression tray or using silicone putty

as shown in Figure 6.

6. Orthodontics

Teeth which may be malpositioned buc-

cally/labially through development may

have a buccal dehiscence and associated

recession as discussed previously. This is

oten seen in buccally placed lower inci-

sor teeth where there is crowding o the

lower labial segment. In some cases sur-

gical intervention and grating may help

to treat the recession deect; however, i

orthodontic treatment is an option that

the patient is willing to consider then any

surgical intervention should be delayed

until ater orthodontic tooth movement

has been completed. Studies have shown

that orthodontic movement o the tooth

lingually allows alveolar bone growth on

the buccal aspect, thickening o the gin-gival tissue and subsequent coronal shit

in the gingival margin resulting in correc-

tion o the recession deect. I ollowing

orthodontic treatment surgical interven-

tion is still indicated the outcome is likely

to have higher predictability than i it was

perormed beore orthodontic treatment.2,18

CONCLUSION

Gingival recession is oten seen in the

patients presenting to the general den-

tal practitioner or restorative special-

ist. Many o these patients can oten be

treated simply by employing the non-sur-

gical techniques discussed above. In some

cases surgical intervention may be neces-

sary and subsequent papers in this series

aim to discuss the surgical management

o recession.

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2. Baker P, Spedding C. The aetiology o gingivalrecession. Dent Update 2002; 29: 59–62.

3. Gorman W J. Prevalence and etiology o gingivalrecession. J Periodontol 1967; 38: 316–322.

4. Akerly W B. Prosthodontic treatment o traumaticoverlap o the anterior teeth. J Prosthet Dent 1977; 38: 26–34.

5. Er N, Ozkava A, Berberoglu A, Yamalik N. An unu-sual cause o gingival recession: oral piercing. J Periodontol 2000; 71: 1767–1769.

6. Wennstrom J L. Mucogingival therapy. Ann

Periodontol 1996; 1: 671–701.7. Zalkind M, Hochman N. Alternative method o con-

servative esthetic treatment or gingival recession. J Prosthet Dent 1997; 77: 561–563.

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Assoc 2003; 134: 295–304.9. Gill D S, Naini F B, Tredwin C J. Smile aesthetics.

Dent Update 2007; 34: 152–154, 157–158.

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11. Davis N C. Smile design. Dent Clin North Am 2007; 51: 299–318, vii.

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Potassium containing toothpastes or dentinehypersensitivity. Cochrane Database Syst Rev 2006; (3): CD001476.

13. West N X. Dentine hypersensitivity: preventive andtherapeutic approaches to treatment. Periodontol 2000 2008; 48: 31–41.

14. Al-Sabbagh M, Brown A, Thomas M. In-oce treat-ment o dentine hypersensitivity. Dent Clin NorthAm 2009; 53: 47–60.

15. Barzilay I, Irene T. Gingival prostheses - a review.J Can Dent Assoc 2003; 69: 74–78.

16. Carvalho W, Barboza E P, Gouvea C V. The use o porcelain laminate veneers and a removable gingivalprosthesis or a periodontally compromised patient:

a clinical report. J Prosthet Dent 2005; 93: 315–317.17. Lai Y L, Lui H F, Lee S Y. In vitro color stability, stain

resistance, and water sorption o our removablegingival fange materials. J Prosthet Dent 2003;90: 293–300.

18. Wennstrom J L. Mucogingival considerations inorthodontic treatment. Semin Orthod 1996; 2: 46–54.

Figs 5a-c Gingival veneer used to correctrecession caused by periodontal disease

a

b

c

Fig. 6 Two part impression technique or

gingival veneer

254 BRITISH DENTAL JOURNAL VOLUME 211 NO. 6 SEP 24 2011

gingival recession. part 1. nonsurgical management

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