gingival recession—can orthodontics be a cure? evidence from a case presentation

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  • Case Report

    Gingival recessioncan orthodontics be a cure?

    Evidence from a case presentation

    William M. Northwaya

    ABSTRACTDoes orthodontic treatment help or hinder a patients periodontal status? What factors affect theperiodontium? Can those factors be managed in a way that remedies existing periodontal issues?A 35-year-old woman presented with severe gingival recession and a unilateral Class IImalocclusion. The treatment plan was to correct the malocclusion in a way that torques the rootsmore onto bone and to change her dental hygiene methods. With an extensive review of theliterature, this case review attempts to make sense of the enigma of gingival recession anddemonstrates an excellent treatment solution to concomitant orthodontic and periodontalproblems. (Angle Orthod. 2013;83:10931101.)

    KEY WORDS: Gingival recession; Oscillating toothbrushing; Orthodontic root torque; CBCT;Digital study casts


    Contemporary orthodontics is more than biomechan-ical wizardry; it incorporates a concept of periodontalphysiology as well. Perhaps first among the advocatesof this breadth of approach was Vanarsdall.1 He taughtthat normal gingiva has a thick band of keratinizedtissue that helps resist attrition and disease. Soimportant is the health of this gingival band that hehas advocated that its character should be a diagnosticcriterion in determining whether tooth extraction isindicated in an orthodontic patient. A healthy tooth sitson alveolar bone with a healthy gingival apparatus.

    Dorfman2 wrote that the presence of keratinizedtissue might be an indicator that mucogingival prob-lems will be less likelyeven in cases whereorthodontic proclining of the lower incisors mightprovide more fullness to the facial profile. Pearson3

    tested the impact of tipping lower incisors on recessionduring orthodontic treatment and found that among hispatients there was no correlation between the amountof root apex advancement or retraction and the degreeof recession. In 2008, the featured cover article in theJournal of the American Dental Association was an

    exhaustive review of the literature that found thatorthodontics provided little benefit to the periodontium;in fact, the net response was small but detrimental.4

    The objective of this article is to discuss the relation-ship between the development of a healthy periodon-tium and the potential impact of orthodontics, toadvocate for modifications in orthodontic treatmentthat might improve the periodontal prognosis, and topresent a treatment report that demonstrates concom-itant orthodontic and periodontal benefits.

    According to Wennstrom et al.5 the gingiva iscomposed of dense, collagen-rich tissue covered bya keratinized epithelium that extends from the softtissue margin to the mucogingival line. It comprises thefree portion (which corresponds to the probing depth)and the attached portion. Ideally, the tooth will erupt onthe crest of the alveolar arch, surrounded by dense,keratinized tissue that will become well establishedcircumferentially. The gingival dimensions will grow asthe tooth erupts. Wennstrom references Andlin-Sobocki6 and Bimstein and Eidelman,7 who contendedthat gingival height will increase with growth. Ainamoand Talari8 stated that data on gingival dimensions inadults indicate that there is a tendency of increasedapico-coronal width with age. When it comes toresponse to tooth movement within the arch, Wenn-strom5 stated that a more lingual positioning of thetooth results in an increase of the gingival height on thefacial aspect with a coronal migration of the soft tissuemargin. The opposite will occur when changing to amore facial position in the alveolar process. When the

    a Private practice, Traverse City, Mich.Corresponding author: Dr William M. Northway, 12776 S West

    Bay Shore Dr, Traverse City, MI 49684(e-mail:

    Accepted: April 2013. Submitted: January 2013.Published Online: June 7, 2013G 2013 by The EH Angle Education and Research Foundation,Inc.

    DOI: 10.2319/012413-76.1 1093 Angle Orthodontist, Vol 83, No 6, 2013

  • marginal tissue is apical to the cementoenameljunction (CEJ), it is called gingival recession (GR).

    Gingival Recession

    The periodontium is the protecting barrier againstdisease; once it begins to break down, the toothbecomes susceptible to further destruction and loss.As Daprile et al.9 have shown, in modern societyperiodontal disease can begin as a result of poor oralhygiene, or it can be the result of exaggerated hygienicmeasures that abuse the gingiva. It can also resultfrom an acute traumatic episode that does not healproperly. Chronic trauma can cause detachment of thegingival margin in the form of an irregular attachmentof a frenum. More recently, there has been discussionof a genetically based susceptibility that is manifest invarious types of gingival integrity, known as biotype(thick or thin).10

    Although our presumed knowledge of the interde-pendence of orthodontics and GR seems to beubiquitous, the specifics continue to evolve. Despitemany studies on growth and the effects of orthodonticson the dentition, not until relatively recently hasreference been made to the periodontium. In 1977,Bernimoulin and Curilovic11 debunked the correlationbetween GR and tooth mobility and the correlationbetween tooth mobility and alveolar bone dehiscence.While they found a positive, significant correlationbetween GR and bone dehiscence, they questionedthe impact of trauma from occlusion.

    More germane to the realm of orthodontics, reces-sion can occur during development in the form ofinsufficient space for the dentition on an alveolar ridge.As the discrepancy between tooth mass and availablespace increases, teeth become more crowded and areultimately pushed off the ridge, compromising thesupporting bone. Thus, the likelihood of recessionincreases. The process begins in the form of dehis-cences or fenestrations. Once these have formed, theabsence of alveolar bone makes it more difficult forhealthy gingival tissue to persist in the form of aprotective barrier.

    Staufer and Landmeser12 explored the effects ofcrowding on the dentition and found a degree of correlationamong young patients between crowding and toothinfractions and tooth fractures. Among adults crowdingcorrelated with periodontal pockets and GR. They showedthat in cases of more than 5 mm of crowding, GR of morethan 3.5 mm was 12 times more likely.

    Richman13 examined 72 teeth from 25 consecutivelytreated patients with facial clinical GR of more than3 mm. He used cone-beam computed tomography(CBCT) and showed that although all of the teeth wereperiodontally healthy, they all had significantly prom-

    inent facial tooth contours and associated alveolarbone dehiscences. He pointed out that conventionalorthodontic space analysis does not evaluate thebuccolingual (sagittal) dimension of the tooth orassociated alveolar bone. He developed the radio-graphic supporting bone index (RSBI), which is thesagittal difference between the alveolar bone width,measured 23 mm apical to the CEJ, the width of thetooth measured at that level. He divided his sampleinto three groups, classes A, B, and C, which hadvarying amounts of bone support and consequentialrisk. The hypothesis he proposed was that orthodonticmovement in the direction of risk would likely exacer-bate the periodontal status and cause GR. In his study,he found that more than 75% of the patients who havereceived premolar extraction demonstrate clinicallysignificant gingival recession, leading him to concludethat these patients were compromised from the outsetby reduced RSBI.

    Managing Recession

    Trying to become informed on the subject of GR isnot unlike joining Alice in her visit to Wonderland. Thecloser one looks, the less clear the picture becomes.Daprile et al.9 reported on a 5-year study of dentalstudents, wherein the number of subjects with at leastone site of recession increased significantlyas didthe total number of foci. Whats more, the percentageof affected sites increased with the level of oralhygiene education, and this increase was despite areduction in harmful dental hygiene habits.

    Of the 174 fifteen-year-olds in the sample studied byBjorn et al.,14 an astounding 62% showed some degreeof GR on the labial of maxillary teeth. Interestingly, thegroup with an unspecific toothbrushing techniquehad fewer lesions than the group that used the roll orvibratory technique. The authors speculated that thedifference might not have been the technique but thefact that the unspecific group was paying less attentionto their oral hygiene.

    Loe et al.15 compared samples from Norway and SriLanka and found that more than 60% of Norwegianchildren had recession by age 20 (compared with 30%in Sri Lanka), and that increased to more than 90% atage 50 (compared with 100% of Sri Lankans by age40). As the Norwegian recession was largely on thebuccal and that of the Sri Lankan cohort was moregenerally distributed, the researchers conjectured thatseveral factors were involved, that much of theNorwegian recession seemed to be more related tomechanical abrasion associated with excessive hy-giene systems as opposed to recession caused moreby periodontal disease in the Sri Lankan sample.Khocht et al.16 also reported an increase in the

    1094 NORTHWAY

    Angle Orthodontist, Vol 83, No 6, 2013

  • frequency of recession with age; regression analysisshowed that recession increased 3.5% per decade.The researchers attributed the damage to theincreased frequency of brushing and especially tohard bristles.

    Susin et al.17 examined 1460 urban Braziliansranging in age from 14 to 103 years selected fromvarious geographic areas and stratified by incomelevel. Of these, 83.4% showed recession of 1 mm ormore. The prevalence, extent, and severity of reces-sion were each co


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