Classification and treatment of recessions

Classification and treatment of recessions

1. DEFINITIONS:
2. Definition of recessions:

Gingival recession is defined as the progressive exposure of the root surface of a tooth resulting from the apical migration of the junctional epithelium and the gingiva. This term indicates a comparable resorption of the alveolar bone and the periodontal ligament

2. Treatment or recovery of recessions  :

It is part of muco-gingival surgery which is defined as: All periodontal surgical techniques aimed at correcting defects in morphology, position and/or quantity of gum. 

2. CLASSIFICATIONS OF RECESSIONS:
3. Classification by Sullivan and Atkins (1968): 

• Class 1: Superficial and narrow 
• Class 2: Deep and narrow 
• Class 3: Superficial and wide 
• Class 4: Deep (>3 mm) and wide (>3mm) • 

2. Benqué classification (1983)

• U-shaped recessions 
• V-shaped recessions 
• Recessions in I  

3. Miller classification (1986) 

• Class 1: The lesion does not extend beyond the mucogingival junction. 
• Class 2: The lesion reaches or exceeds the mucogingival junction. 
• Class 3: The lesion reaches or exceeds the mucogingival junction. In addition, there is loss of interdental papillae and underlying bone, but always in a coronal situation of the vestibular or lingual gingival recession. 
• Class 4: The lesion reaches or exceeds the mucogingival junction. The loss of papillae and interdental bone reaches the same level as that of gingival recession.

4. Cairo classification in 2017:

Type 1 Recession (RT1)	No loss of interproximal attachment. The interproximal enamel-cement junction is clinically undetectable on the mesial and distal aspects of the tooth.
Type 2 recession (RT2)	Loss of interproximal attachment ≤ loss of vestibular attachment
Type 3 Recession (RT3)	Interproximal attachment loss > vestibular attachment loss

3. CLINICAL AND RADIOLOGICAL SIGNS:
   1. Clinical signs:

Clinically, gingival recession is noted because the marginal gingival crest is located apically to the cementoenamel junction. The tissues may be red and inflamed or pink and firm, depending on the amount of local irritants present. In both cases, the gingiva is usually thin and fragile, with little or no attached gingiva. The teeth are often prominent in the arch relative to adjacent teeth. Gingival recession can occur at any age, with greater frequency as age increases. 

2. Radiographic signs:

There are no characteristic radiographic signs of gingival recession on the vestibular and lingual surfaces of the teeth. Neither soft tissue changes nor vestibular and lingual heights of the alveolar bone can usually be detected on a dental radiograph. 

4.  PATHOGENESIS: 

The mechanism of gingival recession is not yet fully understood. A certain proportion of gingival recession is considered to be part of aging and a normal result of passive eruption. However, some researchers believe that all recession is a pathological phenomenon. In all cases, the process is a progressive apical migration of the junctional epithelium and a simultaneous destruction of the gingiva, alveolar bone, and periodontal ligament. Gingival recession is often the consequence of inflammatory tissue transformations associated with periodontitis. But recession can also occur in tissues that appear healthy. 

Classification and treatment of recessions

5. ETIOLOGY: 

Although the exact etiology of gingival recession is unknown, the following factors are considered to play a role in the development of this pathology: 

• Bacterial plaque, tartar, over-contoured restorations, and overflowing fillings cause inflammatory tissue changes. 
• Dentures can encroach on the gum tissue. Brushing teeth can cause abrasion, especially with a hard brush and a horizontal brushing motion. 
• The protruding position of teeth on the arch predisposes to recession by causing thinning of periodontal tissues and dehiscence of the alveolar bone.
• Excessive occlusal forces may cause resorption of thin buccal or lingual root bone and thus predispose the overlying gingiva to recession. Occlusal overloads, however, do not directly cause apical migration of the junctional epithelium or gingival recession. 
• Muscle frenulums or attachments that exert tension on the marginal gingiva and create areas of sagging of the marginal gingiva predispose to plaque accumulation. 
• Insufficient height of attached gingiva. 

6. FACTORS IN CHOOSING A RECOVERY TECHNIQUE:

Generally speaking, the simplest or most reproducible surgical technique is always preferred, and the patient must be informed of the possible postoperative consequences, as well as the possible objectives in terms of recovery.

The choice of surgical technique depends on:

• Height and width of the recession: the larger the surface to be covered, the better the vascular support of the grafted tissue must be, hence the interest in the pedicled or buried graft;
• Height of keratinized tissue at the level of the recession and adjacent teeth: this tissue can, if it is of good quality, be pulled coronally or laterally;
• Vestibule depth: if the vestibule is shallow the surgical coverage technique must also recreate a mucogingival complex compatible with good plaque control;
• The number of recessions: in order to avoid multiplying the number of interventions, the greatest number of recessions is treated in one session.

7. FLAP TECHNIQUES:

Pedicled gingival grafts are classified according to flap  displacement :

1- Laterally rotated or displaced flap: – laterally repositioned or transpositioned, – bipapillary;

2-Flap displaced or repositioned without rotation or lateral displacement: coronally displaced and semilunar flap. (See the course of flap interventions).

All these techniques require careful and non-aggressive mechanical surfacing of the root. Root preparation can be completed by burnishing using a chemical agent.

3-Graft techniques: there are 2 types of grafts: Epithelial-connective grafts (free grafts); buried connective grafts. (See muco-gingival surgery course).

Classification and treatment of recessions

8. FORECAST: 

The possibility of preventing further tissue loss in areas of gingival recession depends on the severity and etiology of the recession. In general, if the recession has not reached the apical half of the root and if the etiological factors can be identified and corrected, the prognosis for preventing further recession is favorable. Of particular interest is the ability to reestablish an adequate amount of attached gingiva, a tooth position and contour located within the alveolar space, and an adequate level of nontraumatic plaque control.

Classification and treatment of recessions

  Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.
 

Classification and treatment of recessions