Introduction

Gingival recession can be defined as the apical shift ofthe marginal gingiva from its normal position on thecrown of the tooth to levels on the root surfacebeyond the cemento-enamel junction.1 The preval-ence of gingival recession ranges from 7 per cent to 10per cent in 7 to 15 year-olds.2–4 However, Ainamo etal.4 also reported gingival recession in 48 per cent and72 per cent of 12 and 17 year-olds respectively in aFinnish sample. In the United Kingdom a 1 per centincidence of true gingival recession within a sample of 15 year-olds has been reported.5 The varied pre-valence rates may be attributed to variation in the ageof the sample patients and ethnic groups studied, andthe definitions and methods used to assess gingivalrecession.6,7 Indeed, Volchansky and Cleaton-Jones8

have suggested that gingival recession cannot be diag-nosed with certainty before the age of 12 due to delayin maturation of the gingival tissues. In terms of indi-vidual distribution between teeth, the lower incisorsare commonly affected in younger patients with boththe canine and premolars affected in older children.4

The aetiology of gingival recession can be dividedinto developmental (predisposing) and acquired (pre-cipitating) factors, but ultimately both act together tocause the destruction of the periodontium.6,7

Predisposing factors include labial displacement ofteeth, width of the attached gingivae and a high frenal attachment, and precipitating factors includegingival trauma and poor oral hygiene.

Labial displacement of teeth may develop due toectopic eruption or dental crowding; such teeth

Australian Orthodontic Journal Volume 25 No. 1 May 2009 © Australian Society of Orthodontists Inc. 200976

Orthodontic treatment of localised gingival recession associated with traumatic anterior crossbite

Jadbinder Seehra,* Padhraig S. Fleming† and Andrew T. DiBiase*

Maxillofacial Unit, Kent and Canterbury Hospital,* and the Royal London Dental School,† United Kingdom

Background: Gingival recession can be defined as the apical shift of the marginal gingiva from its normal position on thecrown of the tooth to levels on the root surface beyond the cemento-enamel junction. The aetiology of this condition is multifactorial, but can result from a traumatic occlusion. The long-term prognosis of teeth with localised gingival recession canbe uncertain. Successful management of these cases may involve either orthodontic or periodontal treatment in isolation or incombination.Aim: To describe two patients in which localised gingival recession associated with anterior crossbites were corrected withorthodontic appliances.Methods: A 2 x 4 appliance and an upper removable appliance were used to correct the crossbites.Results: Correction of the anterior crossbites resulted in a clinical improvement of the gingival recession. The aetiology and management of localised gingival recession is discussed.Conclusions: Simple orthodontic appliances can be used to provide interceptive treatment to correct localised crossbite and enhance the overall long-term prognosis of the lower incisors. To achieve optimal results multidisciplinary involvement is recommended.(Aust Orthod J 2009; 25: 76–81)

Received for publication: November 2008Accepted: January 2009

Jadbinder Seehra: Jad_Seehra@hotmail.comPadhraig Fleming: padhraigfleming@hotmail.comAndrew DiBiase: Andrew.Dibiase@ekht.nhs.uk

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generally have a thin covering of alveolar bone ontheir labial surface covered by a correspondingly thinlayer of keratinised mucosa or occasionally devoid ofkeratinised mucosa. These areas are therefore suscep-tible to bony dehiscence formation and gingivalrecession precipitated by periodontal disease andtrauma; both Parfitt and Mjör2 and Stoner andMazdyasna5 recorded increased gingival recession inlabially positioned teeth. Conversely, Andlin-Sobocki9 reported in a 2-year longitudinal study thatthe amount of keratinised and attached gingiva maychange following tooth movement in either a buccalor lingual direction. Lingually positioned teeth wereassociated with increased keratinised gingival widthand a reduced clinical crown height.

Lang and Loe10 reported at least 2 mm of keratinisedgingiva, corresponding to 1 mm of attached gingiva,is required to maintain gingival health. A decreasedwidth of mucosa will be prone to recession caused bymechanical and biological trauma i.e. toothbrushingand plaque retention. However, this association hasbeen questioned by Freedman et al.11 who reportedno difference in recession between sites devoid ofattached mucosa and those which had up to 2 mm ofattached mucosa present.

In the presence of an inadequate zone of attachedmucosa a high frenal attachment can pull the gingivaltissues away from the tooth surface, allowing the accu-mulation of plaque leading to gingival inflammationand recession.12

An aggressive toothbrushing technique has beendescribed as a precipitating factor in gingival recession. The high incidence of gingival recessionreported by Ainamo et al.4 in both 12 and 17 year-olds was attributed to toothbrushing trauma.However, Zamet12 suggested both a bony dehiscenceand thin keratinised mucosa are significant factors.Recently, lip piercings have been cited as causes oflocalised gingival recession.13 A cross-sectional studyperformed by Kapferer et al.14 reported a significantcorrelation between gingival recession and the timeelapsed since placement of the piercing. This findingsuggests chronic mechanical trauma as a significantaetiological factor. Occlusal trauma from an existingmalocclusion can lead to gingival recession. An example of this is Class II division 2 malocclusionwith an increased overbite where ‘stripping’ of thelabial mucosa of the mandibular incisors occurs; similarly, gingival recession palatal to the upper

incisors may also result from an impinging overbite.15

Inadequate plaque control leading to the accumul-ation of supra- and subgingival calculus may result ingingival recession.6 Conversely, gingival recession isalso common in patients with excellent oral hygieneas a consequence of overzealous toothbrushing.16

A common clinical presentation of localised gingivalrecession is a prominent mandibular incisor withreduced or absent keratinised gingiva. Parfitt andMjör2 reported the lower central incisors to be morecommonly affected than the lower lateral incisors.Indications for treatment include: aesthetics, gingivalinflammation/pocketing, sensitivity and root caries.We present and discuss two clinical cases in whichsevere localised gingival recession associated withlocalised anterior crossbites were treated using differ-ent orthodontic treatment modalities resulting in aclinical improvement in the gingival architecture.

Case 1

A medically fit and well 10 year-old male was initi-ally referred to the orthodontic department by hisgeneral dental practitioner for advice regarding areverse overjet involving the upper left central incisor(UL1) and severe gingival recession of the opposinglower left central incisor (LL1). The patient pre-sented in the mixed dentition with a Class III incisorrelationship (localised to the UL1) on a mild skeletal3 pattern with a slightly increased lower facial heightand maxillary mandibular planes angle. On examina-tion both the upper and lower labial segments wereretroclined with mild crowding. The UL1 was incrossbite; a reverse overjet of 1 mm was measured onthe UL1 with no displacement on closure detected.Both maxillary canines were unerupted and palpatedin the labial sulcus. Five millimetres of gingival reces-sion was noted on the labial surface of the LL1(Figure 1). However, no mobility of this tooth wasdetected. Oral hygiene was poor with generalisedsupragingival plaque deposits. A diagnosis of trau-matic occlusion of the LL1 was made. Treatment aimsincluded reinforcement of oral hygiene, correction ofthe localised anterior crossbite and prevention of fur-ther gingival recession of the LL1.

Following banding of the UR6 and UL6, a pre-adjusted appliance (2 x 4 appliance), slot size 0.022 x0.028 inch, with MBT prescription was bonded tothe UR2, UR1 and UL2. A 0.014 inch NiTi archwire

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was ligated and NiTi coil spring activated to openspace for the UL1 at the first visit (Figure 2). At thefollowing visit, glass ionomer build-ups were placedon the occlusal surfaces of both lower first molars.The UL1 was bonded and a 0.016 inch NiTi arch-wire ligated allowing unimpeded labial movement ofthe UL1 and achievement of a positive overjet andoverbite. Overall treatment time was approximately 3 months, requiring 3 visits.

At debond, an improvement in the position of theLL1 and gingival recession (3 mm) was noted (Figure3). Both the patient’s dental development and thegingival health of the LL1 continue to be monitored.

Case 2

A medically fit and well 10 year-old male was referredto the orthodontic department by his general dentalpractitioner for advice regarding a localised anteriorcrossbite involving the upper right central incisor(UR1). The patient presented in the mixed dentitionwith a Class III incisor relationship (localised to theUR1) on a skeletal 1 pattern with an average lowerfacial height and maxillary-mandibular planes angle.On examination both the upper and lower labial seg-

ments were of average inclination with mild crowdingof the upper labial segment. The UR1 was in cross-bite; a reverse overjet of 1 mm was measured on theUR1 with displacement of UR1 on closure. Bothmaxillary canines were unerupted and palpated in thelabial sulci. Intra-orally 3.5 mm of gingival recessionwas noted on the labial surface of the LR1 (Figure 4).Oral hygiene was of a poor standard with generalisedsupragingival plaque deposits. A diagnosis of traumatic occlusion of the lower right central incisor (LR1) was made. Treatment aims includedreinforcement of oral hygiene, correction of thelocalised anterior crossbite (UR1) with removal of thedisplacement on closure and prevention of furthergingival recession of the LR1.

An upper removable appliance was constructed andfitted to correct the localised anterior crossbite (Figure5). Both the retentive and active components of theappliance were reviewed on a monthly basis. Overalltreatment time was 4 months requiring 6 visits.

Following cessation of appliance therapy an improve-ment in the position of the LR1 and gingival reces-sion (2.5 mm) was noted (Figure 6). Both thepatient’s dental development and the gingival health

Figure 1. Case 1. Initial presentation of the severelocalised gingival recession of LL1 and anteriorcrossbite.

Figure 4. Case 2. Presenting appearance of thesevere localised gingival recession of LR1 and anterior crossbite.

Figure 5. Upper removable appliance in situ. Figure 6. Improved clinical appearance of the gingival height of LR1.

Figure 3. At debond an improvement of the clinically appearance of the gingival height (LL1) is apparent.

Figure 2. The 2 x 4 sectional appliance. Steel tubing was placed in the buccal segments to sup-port the flexible archwire. The UL1 was bonded following opening of the bite with glass ionomercement.

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of the LR1 continue to be monitored. Oral hygieneinstructions were reinforced.

Discussion

Classically, a removable appliance consisting of anacrylic baseplate, Adams cribs on the upper first per-manent molars and premolars, a posterior bite planeand T-springs or Z-springs has been prescribed for thecorrection of a localised anterior crossbite. A similardesign was used in Case 2. The design consisted of anacrylic baseplate, Adams cribs on the UR6 and UL6,ball-ended clasps between the contact points of the upper primary molars, bilateral posterior cappingand a Z-spring palatal to the UR1 (Figure 7).Disadvantages of this type of appliance include thereliance on patient co-operation and compliance towear the appliance and, critically, the teeth are onlytipped and are not under the full control of the clini-cian. Another major issue is poor retention especiallywhen used in the mixed dentition; this necessitatedmore regular recall culminating in more treatmentvisits compared to the sectional fixed appliance.

The uses of the 2 x 4 appliance have been previouslydescribed by both McKeown and Sandler17 andSkeggs and Sandler.18 A sectional fixed appliance isideal at providing interceptive treatment in the mixeddentition. The fixed appliance allows excellent control of the tooth in all three spatial planes.Consequently, a fixed appliance was chosen in Case 1as more significant malalignment was present at theoutset, necessitating space creation and controlledtooth movement. A removable appliance was preferred in Case 2 as the inclination of the UR1 wasthe chief problem with the upper labial segment

being generally well-aligned. The fixed applianceplaces a lesser premium on patient compliance, hencepotentially reducing overall treatment time.17,18 Inaddition, retention is improved and easily achievedwith the use of bonding agents rather than reliance ontooth undercuts.

The documented cases both demonstrate gingivalrecession associated with a traumatic occlusion.However, it is unlikely that the severe degree of reces-sion extending to the root surfaces exhibited in bothcases is solely due to occlusal trauma. Plaque-inducedgingival inflammation was a significant contributingfactor in this aetiology. The clinical improvementresulted from lingual movement of the lower incisorsfollowing orthodontic correction of the localisedcrossbite. This was facilitated by orthodontic toothmovement in addition to improvement in oralhygiene and the absence of calculus deposits. Theintimate relationship between levels of plaque controland presence of periodontal disease is well-estab-lished, while the clinical improvement in gingivalinflammation and periodontal destruction is relianton both preventive dental treatment and self-performed plaque removal.19

Interestingly, Davies et al.19 reported that teeth incrossbite are also prone to greater plaque accumul-ation. In contrast, Andlin-Sobocki20 reported in asample of children aged 6–13 years a reduction ingingival recession localised to the mandibular incisorswhen a high level of oral hygiene was maintained. Atbaseline an average of 2 mm gingival recession waspresent which reduced to 0.5 mm over a 3-year period; the value of optimal oral hygiene cannot beunderestimated. Indeed, the difference in clinicalimprovement between the two cases may be attrib-uted to a lesser improvement in oral hygiene by thepatient in Case 2. In contrast, Eismann and Prusas21

reported that the mean improvement of the gingivallevel of orthodontically treated mandibular incisors incrossbite was 1.1 mm. Clearly it is difficult to differ-entiate between the effects of treatment and improvedoral hygiene; however, it is extremely likely that thesemeasures have a synergistic effect.

When planning orthodontic treatment in these clinical situations the overall malocclusion should beconsidered, as highlighted by Case 1. In a mildlycrowded case of this nature without associated perio-dontal destruction, treatment may have been post-poned until the establishment of the permanent

Figure 7. Diagrammatic view of modified URA used to correct the localised anterior crossbite in Case 2.

dentition. The interceptive treatment performed inthese cases is likely to be stable due to the attainmentof a positive overbite following removal of the appli-ances (Figures 3 and 6). Furthermore, the absence ofa significant sagittal skeletal discrepancy in either caseensures that further adverse mandibular growthresulting in recurrence of the anterior crossbite isunlikely. In the present cases, interceptive treatmentwas necessitated by the periodontal destruction,which had both aesthetic and dental health conse-quences. Placement of a lower appliance in the mixeddentition would, however, have been ineffective dueto the likelihood of further lower incisor advance-ment due to the mandibular arch crowding.

The long-term treatment plan in both cases includesmaintenance of optimal oral hygiene and monitoringof both the developing occlusion and gingival level.The need for gingival surgery remains a possibility inboth cases, although this would only be necessitateddue to aesthetic concern or the development of sensi-tivity. Vergara and Caffesse22 reported excellent rootcoverage and an increased amount of keratinised gingiva using an envelope surgical technique in 50consecutive patients with localised gingival recession.The benefits of guided tissue regeneration versus con-nective tissue grafts in the treatment of localised gingival recession have been investigated by Cetineret al.23 with similar clinical outcomes reported forboth techniques; however, connective tissue graftsresulted in greater levels of keratinised tissue.Whether surgical grafting should be performedbefore or after orthodontic tooth movement remainsquestionable. Maynard and Ochsenbein24 suggestthat where insufficient (1 mm or less) keratinised tis-sue exists, a free gingival graft should be performedprior to orthodontic tooth movement. However,Ngan et al.25 reported that pre-orthodontic graftingof mandibular incisors with recession did not signifi-cantly further decrease the amount of post-orthodonticrecession. In both cases gingival grafting was not con-sidered before appliance therapy as greater than 1 mmof keratinised gingival tissue was present.

Conclusions

The above cases demonstrate the diagnosis and man-agement of localised gingival recession associatedwith an anterior crossbite. Two simple orthodonticappliances were used to provide interceptive treat-ment to correct the malocclusion and to enhance the

overall long-term prognosis of the lower incisors. Toachieve optimal results multidisciplinary involvementis recommended.

Corresponding author

Mr Jadbinder SeehraMaxillofacial UnitKent and Canterbury HospitalEthelbert RoadCanterburyKent CT1 3NGUnited Kingdom Email: Jad_Seehra@hotmail.com

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