Refresher on Gingival Recession

Etiology

Gingival recession can be described as exposure of the root surface due to apical displacement of the gingival margins along with other components of the periodontium.

Etiological factors predisposing to gingival recession include:

• Periodontal inflammation
• Tooth brush abrasion and trauma
• Overhanging restoration margins which lead to plaque accumulation and inflammation
• Bone dehiscence and fenestration
• Orthodontic tooth movement
• Viral and drug-induced ulceration of marginal gingiva
• Blood dyscrasias such as neutropenia
• Obstruction of blood supply or ischemic condition of gingiva

Classification

Based on the morphology and likelihood of root coverage (full or partial root coverage) Miller has classified local recession defects into 4 classes:

• Class 1: Gingival recession not extending beyond the mucogingival junction and no loss of interdental soft tissue or bone.
• Class 2: Gingival recession extending beyond the mucogingival junction but no loss of interdental soft tissue or bone.
• Class 3: Gingival recession extending beyond the mucogingival junction with loss of interdental soft tissue and bone. Interdental soft tissue and bone margins are apical to cementoenamel junction but coronal to recession.
• Class 4: Gingival recession extending beyond the mucogingival junction with loss of interdental soft tissue and bone. Interdental soft tissue and bone margins are apical to recession.

Treatment

Complete root coverage can be achieved in Class 1 and 2 recession defects (less than 5mm). However, prognosis for complete root coverage is poor for class 3 recession defects and it is unlikely to achieve complete root coverage in class 4 recession defects.

Based on the morphology and the type of  defect as well as availability of keratinized gingiva, various mucogingival procedures can be utilized to correct the recession defects. These procedures include free gingival soft tissue grafts, subepithelial connective tissue grafts, coronally and laterally positioned flaps and guided tissue regeneration. The guidelines are as follows:

• If gingival recession is evident, but adequate zone of attached gingiva is not present, free gingival graft, coronally repositioned flap, and connective tissue grafts are the treatments of choice. However, the use of free gingival grafts in esthetic zones is no longer recommended.
• If gingival recession is <2mm and an adequate zone of attached gingiva is present, a coronally positioned flap is the treatment of choice.
• If the recession is >2mm and an adjacent donor site has an adequate zone of attached gingiva, a lateral repositioned flap is the treatment of choice. However, if an adequate adjacent donor site is not present, coronally repositioned flaps and connective tissue grafts remain the treatments of choice.

Of the aforementioned flap techniques, sub epithelial connective tissue grafts are considered to be the most predictable and a highly effective root coverage procedure.

Reference

Nairn Wilson (2014). Principles and practice of esthetic dentistry: Essentials of esthetic dentistry. London, UK: Elsevier Health Sciences.