One of the most common esthetic concerns associated with the periodontal tissues is gingival recession. Gingival recession is the exposure of root surfaces due to apical migration of the gingival tissue margins; gingival margin migrates apical to the cementoenamel junction. Although it rarely results in tooth loss, marginal tissue recession is associated with thermal and tactile sensitivity, esthetic complaints, and a tendency toward root caries. This paper reviews etiology, consequences, and the available surgical procedures for the coverage of exposed root surfaces, including three case reports.
Gingival recession is a problem affecting almost all middle and older aged to some degree. Gingival recession is the apical migration of gingival margin to the cementoenamel junction (CEJ). The distance between the CEJ and gingival margin gives the level of recession. Gingival recession can be caused by periodontal disease, accumulations, inflammation, improper flossing, aggressive tooth brushing, incorrect occlusal relationships, and dominant roots. These can appear as localized or generalized gingival recession. Recession can occur with or without loss of attached tissue. Gingival recession may effect in accentuated sensitivity because of the exposed dentin, it can be assessed by an appearance of a long clinical tooth and varied proportion of the teeth when compared with adjacent teeth.
According to the US National Survey, 88% of seniors (age 65 and over) and 50% of adults (18 to 64) present recession in one or more sites; progressive increase in frequency and extent of recession is observed with increase in age [
In the youngest age cohort (30 to 39 years), the prevalence of recession was 37.8% and the extent averaged 8.6% teeth. In contrast, the oldest cohort, aged 80 to 90 years, had a prevalence of 90.4% (more than twice as high) and the extent averaged 56.3% teeth (more than six times as large) [
Gingival recession is associated with the presence of supragingival and subgingival calculus and showed that the lingual surfaces of the lower anterior teeth were most frequently affected in 20–34 year age group in Tanzanian adult population [
Association between gingival recession with supragingival and subgingival calculus can be noted because of inadequate access to prophylactic dental care [
Khocht et al. showed that use of hard tooth brush was associated with recession [
This may impede plaque removal by causing pull on the marginal gingival [
Tooth which erupts close to mucogingival line may show localised gingival recession as there may be very little or no keratinized tissue [
The movement of tooth such as excessive proclination of incisors and expansion of the arch expansion are associated with greater risk of gingival recession [
The partial dentures which have been maintained or designed which cause the gingival trauma and aid in the plaque retention have the tendency to cause gingival recession [
The people who smoke have more gingival recession than nonsmokers.
The recession sites were found on the buccal surfaces of maxillary molars, premolars, and mandibular central incisors [
Subgingival restoration margins increase the plaque accumulation, gingival inflammation, and alveolar bone loss [
Topical cocaine application causes gingival ulcerations and erosions [
The appearance of tooth becomes unattractive [
The recession may be a site clinically which offers plaque retention.
Recession will uncover the cervical dentine. Hypersensitivity is usually of a sharp and short duration often associated with cold stimulus. The mechanism of hypersensitivity that is accepted is the hydrodynamic theory of pain, which states that the movement of dental fluid in the dentinal tubules triggers sensory nerve fibers in the inner dentine and dentinopulpal junction [
There may be a risk of the development of root caries as root surfaces are exposed to oral environment and aid in the withholding of plaque. Patients on periodontal maintenance with an average of 64.7 exposed root surfaces per patient; the mean number of caries lesions which were detected were 4.3 in a prevalence study [
Crowns may be placed to widen the clinical crown which may camouflage the exposed root surface
Patients who have several teeth with recession may have unaesthetic appearance because of black triangles. In these cases, where surgical procedure is not appropriate, silicone flexible gingival veneer or mask may be used.
Application of tetracycline HCL or citric acid to root surface before placement of soft tissue graft.
When the recession is caused by frenal pull in those cases, frenectomy is advised. If appropriate hygiene aids do not enable the patient to maintain the area plaque free, then frenectomy is advised to give ease to entrance to the site [
Free epithelialised gingival graft [ Subepithelial connective tissue graft [ Semilunar flap [ Coronally advanced flap [ Guided tissue regeneration [GTR] [
A 43-year-old female patient complained of hypersensitivity inspite of using anti-hypersensitivity paste since 2 months and was also concerned about the esthetics. Patient had gingival recession on the maxillary left canine and first premolar at the first examination (Figure
Facial view of gingival recession on 1st premolar and canine. The patient complained of root sensitivity in addition to the unaesthetic appearance when smiling.
Semilunar incision placed apically.
Root conditioning with tetracycline.
Repositioning of the flap coronally.
One -year postoperative view. Complete root coverage is observed.
A 31-year-old female patient complained of a black triangle in the upper front teeth region since 6 months and was concerned about the esthetics and whistling sound while speaking (Figure
Blunting of interdental papilla between central and lateral incisor.
The interdental papilla between maxillary right central and lateral incisor was blunt (Figure
Intrasulcular incision.
Connective tissue graft taken from palate.
Graft placement under the flap.
Placement of suture.
Closure of interdental papilla 6 months postoperatively.
A 25-year-old female patient complained of hypersensitivity in the lower front teeth region since 2 months and was concerned about the esthetics. Patient had gingival recession on the mandibular right central incisor at the first examination (Figure
Recession of right central incisor.
Incisions given for the removal of graft.
View of the palate after removal of the graft.
The donor tissue.
Suturing.
Six months postoperative healing.
The main goal of periodontal therapy is to improve periodontal health and thereby to maintain a patient’s functional dentition right through his/her life. However, aesthetics symbolize an inseparable part of today’s oral therapy, and numerous procedures have been proposed to preserve or enhance patient aesthetics. This treatment has principally been justified by the patient’s wish to advance the aesthetic appearance when there is an exposed root.
Etiology and the contributing factors are chief when deciding on appropriate treatment procedures for patients with localized gingival recession. In the cases presented, the etiologies of the gingival recession were scarce vestibular depth and inadequate width of keratinized gingiva. If malposition of teeth is supposed to be the etiology for recession, then orthodontic treatment needs to be given a thought with or without periodontal therapy. Due to the existence of multiple mucogingival problems, it was decided to use a free gingival graft to accomplish root coverage and to form functional attached gingiva. The band of keratinized tissue was determined to be adequate in all cases. The color match and the tissue contour were satisfactory to the patients in all cases mentioned above. In some cases the color match and tissue contour match were good enough to make it complex to determine the position of the original defect.
The outcome of the current cases confirm aesthetics as the primary indication for root coverage. A recent survey showing that aesthetic concern was the foremost indication for root coverage procedures [
Gingival recession is one of the main esthetic complaints of patients. This also exposes patients to sensitivity and greater risk for root caries. Mucogingival surgery endeavors’ to reestablish the periodontium to a healthy circumstance. Periodontal plastic surgery strives to restore the periodontium to a healthy, efficient, and aesthetic state. For coverage of exposed roots, there is a vast range of mucogingival grafting procedures available in the present epoch. These procedures are quite predictable and produce satisfactory solutions to the problems presented by gingival recessions. Choice of appropriate procedure and surgical technique will recommend successful and exceedingly predictable results in the management of gingival recession.
The present paper suggests that the selection of suitable procedure and specific and meticulous surgical technique will provide successful and exceedingly predictable results in the management of gingival recession.