PERIODONTAL RECESSIONS ETIOLOGIES – CLASSIFICATIONS
Plan
INTRODUCTION
1. REMINDERS ON THE GUM
2. PERIODONTAL RECESSIONS
2.1. Definitions
2.2. Measurement of periodontal recession
2.3. Clinical aspects
3. ETIOLOGIES OF PERIODONTAL RECESSIONS
4. PATHOGENESIS OF PERIODONTAL RECESSIONS
5. CLASSIFICATIONS OF PERIODONTAL RECESSIONS (PR)
5.1. Classifications of periodontal types
- Maynard and Wilson (1980) Seibert and Lindhe (1998)
- Korbendeau and Guyomard (1992)
5.2. Classifications of periodontal recessions Sullivan and Atkins (1968)
- Benque (1984)
- Miller (1985)
- Cairo (2011)
CONCLUSION
PERIODONTAL RECESSIONS ETIOLOGIES – CLASSIFICATIONS
INTRODUCTION
Gingival recessions are often the cause of dentin hypersensitivity and an aesthetic demand in periodontics. This is a frequent reason for consultation. The term periodontal recession is more appropriate because it is the entire periodontium that migrates apically. Historically, the recovery of periodontal recessions has always represented a challenge in periodontics. Periodontal plastic surgery essentially allowed the improvement of the periodontal environment by augmentation of the attached gingiva. It should be remembered that a periodontal recession (PR) does not represent a vital problem. It is essential to correctly establish the therapeutic indication and not to give in to exaggerated cosmetics.
- REMINDERS ON THE GUM
The periodontium is made up of four components: the gingiva, the periodontal ligament, the alveolar bone and the cementum. When root denudation occurs, all the constituent elements are altered, which results in the exposure of the root cementum, the destruction of the alveolar bone and the facing fibers, as well as a more or less significant disappearance of the gingiva (keratinized tissue). The attachment system includes the junctional epithelium and the connective tissue attachment.
- PERIODONTAL RECESSIONS
Mucogingival problems represent a major reason for consultation due to the appearance of clinical signs or aesthetic damage, even if, most often, the durability of the teeth on the arch is not called into question. Mucogingival surgery techniques have evolved considerably over the last 30 years. The indications for preventive surgery have been reduced: gum augmentation is no longer systematic, even in the presence of a thin periodontium. The demand for aesthetic results, in terms of healing, but especially the percentage of coverage of periodontal recessions, has profoundly modified the surgical approach.
PERIODONTAL RECESSIONS ETIOLOGIES – CLASSIFICATIONS
- Definitions
∙ 1977 (Guinard EA & Caffesse RG) RP = partial denudation of the root surface due to apical migration of the marginal gingiva.
∙ 1979 (Glickman): “gingival recession” = “exposure of the dental root to the oral environment due to an apical displacement of the position of the gingiva”.
∙ 1992 (AAP): RG = displacement of the marginal gingiva apically to the enamel-cementum junction.
∙ 1999 (Pini Prato): apical migration of the marginal gingiva under the enamel-cementum junction. All periodontal tissues (attachment, bone and gingiva) are affected by apical migration ⇒ RP. They can be single or multiple and affect all maxillary and mandibular teeth in one or more sectors.
- Periodontal recession measurements
Measuring gingival recessions is essential because the value in millimeters of the recession is an integral part of calculating the attachment level. This measurement is done using the periodontal probe. It is a diagnostic tool but also plays a role in the therapeutic decision and prognosis. It allows determining the depth of the pockets (which defines the need or not for periodontal treatment), the level of clinical attachment or loss of attachment (which defines the presence and severity of periodontitis) and the extent of interradicular lesions. It also allows assessing clinical inflammation at a site when bleeding is observed.
- Clinical aspects
- Unsightly appearance when smiling or laughing, or simply visible root denudation during speech, or not visible except when lifting the lip but which he considers aesthetically disturbing.
- The fear of losing one or more teeth.
- Radicular hyperesthesia, caused in particular by thermal stimuli or by contact.
- Gingival sensitivity to brushing or chewing, especially when the marginal tissue is alveolar mucosa.
- ETIOLOGIES OF PERIODONTAL RECESSIONS
Before treating the lesion(s), it is important to identify the cause of the recession(s), in order to avoid therapeutic failure. The etiology is considered multifactorial:
- predisposing factors
- triggering factors
- Predisposing factors
(Essentially anatomical: bone, mucogingival, dental factors)
o Bone factors:
- Bone dehiscences and fenestrations (see figure 2)
- Thin bone table
o Mucogingival factors:
- Absence or low height and/or thickness of keratinized tissue
- Brake and bridle traction
- Shallow vestibule
o Dental factors:
- Dental malpositions
- Emergence of tooth eruption
- Triggering factors
o Inflammatory and infectious factors: Dental plaque. Non-plaque induced inflammations (bacterial origin – viral origin – fungal origin).
o Traumatic factors: Traumatic brushing (toothbrush too hard – abrasiveness of the toothpaste – technique used – frequency of brushing). Non-carious dental cervical lesions (erosion, abrasion, attrition, abfraction: this is a V-shaped or wedge-shaped lesion (Grippo 1991), explained by tension forces, due to occlusal overloads during eccentric or lateral dental movements). Traumas of various origins (lesions of chemical origin: burns from aspirin contact; physical origin: nail biting, lip and tongue piercing; thermal origin: electric scalpel burns). Occlusal trauma: occlusal overload (prematurity – non-working contacts in laterality, etc.) is not an etiological factor of periodontal disease but a significant aggravating factor.
- Iatrogenic factors
o Crowns and conservative care: Plaque retention at the dento-prosthetic seal; if the seal is intrasulcular, Maynard and Wilson recommend a safety zone of 5 mm of gingiva, including 3 mm of attached gingiva. Non-watertight, crowded restorations.
Failure to respect the biological space ⇒ chronic gingival inflammation which may develop into gingival retraction after bone resorption and ⇒ root denudation.
o Partial removable prostheses / Poorly adapted fixed prosthesis: Teeth supporting hooks; presence of lingual bars; metal prosthesis source of gingival trauma by sinking, in the absence of occlusal supports.
o Surgery: Positioning of a relieving incision in the middle of the vestibular surface of a tooth, and/or non-coaptation of the edges of a relieving incision at the end of surgery. o Orthodontic displacement outside the bony bases.
o Tobacco (cigarette, smokeless tobacco: chewing tobacco – snuff).
o Harmful habits. It is important to clarify that inadequately attached gingiva or bony dehiscences or fenestrations are only risk factors for periodontal recession. This recession will not occur in the absence of a triggering factor.
- PATHOGENESIS OF PERIODONTAL RECESSIONS
Under the effect of trauma or inflammation, acanthotic-type digitations are formed at the level of the junctional epithelium and in the direction of the connective tissue. The digitations progress on the gingiva, which is thin and narrow. We observe a reunion of the digitations, a disappearance of the connective tissue and the creation of a cleft which then widens depending on the etiology, time and position of the tooth. Sometimes, there is the possibility of the creation of a gingival fenestration, a sort of epithelial-connective tissue bridge which survives for some time then disappears and then a recession sets in under the fenestration.
There are two types of lesions that cause recessions:
- Inflammation
- The trauma
Aggressive brushing and piercings, for example, will cause a traumatic lesion. It all starts with an injury with loss of epithelial integrity. This is followed by an inflammatory reaction which, as it progresses in depth, will destroy the connective tissue, while the epithelium will migrate along the edges of the wound. The root surface is then gradually exposed. If we are in the presence of a thin periodontium (type IV of Maynard and Wilson), the phenomenon will cause total tissue destruction with the appearance of a recession. Dental plaque, on the other hand, will cause a pure inflammatory lesion. This progresses in the opposite direction: from the pocket epithelium to the external epithelium. On a thick periodontium, gingival inflammation causes a periodontal pocket. When the periodontium is thin, there is little connective tissue and the fusion of these two epithelia is the cause of root denudation.
PERIODONTAL RECESSIONS ETIOLOGIES – CLASSIFICATIONS
5. CLASSIFICATIONS OF PERIODONTAL RECESSIONS
5.1. Classifications of periodontal types
In order to determine the periodontal types presenting an increased risk of recession, several classifications have been proposed: ¬ Maynard and Wilson (1980) ¬ Seibert and Lindhe (1998) ¬ Korbendeau and Guyomard (1992)
5.1.1. Classification of Maynard and Wilson (1980)
Based on the morphology of the periodontium, it distinguishes 4 periodontal types ranging from the most favorable situation to that presenting the greatest risk of the appearance of a recession.
- type I: keratinized tissue height is sufficient (about 3.5 mm) and periodontium (gingiva and underlying alveolar bone) is thick.
- type II: height of keratinized tissue is reduced (less than 2 mm), but the thickness is normal.
- type III: height of keratinized tissue is normal, but the alveolar process is thin (prominent dental roots).
- type IV: height of keratinized tissue is reduced and the alveolar process is thin.
The risk of periodontal recession increases depending on the class.
5.1.2. Classification of Seibert and Lindhe (1998)
She distinguishes two types of periodontium:
- a flat and thick periodontium (favorable situation)
- a thin, scalloped periodontium (risk situation)
5.1.3. Classification of Korbendeau and Guyomard (1992)
Types C and D represent situations at risk of the appearance of periodontal recessions:
- type A: the alveolar process is thick, close to the cementoenamel junction line, and the gingiva is thick and of sufficient height (greater than 2 mm);
- type B: the alveolar process is thin, close to the enamel-cementum junction line and the gingiva is quite thin but of sufficient height (greater than 2 mm);
- type C: the alveolar process is thin, located more than 2 mm from the enamel-cementum junction line and the gingiva is thin but of sufficient height (greater than 2 mm);
- type D: the alveolar process is thin, located more than 2 mm from the enamel-cementum junction line; the gingiva is thin and of reduced height (less than 1 mm).
5.2. Classifications of periodontal recessions
5.2.1. Sullivan and Atkins (1968) classification
It is based on the width and height of the recession (see Figure 3).
- Deep and wide recessions
- Shallow and wide recessions
- Deep and narrow recessions
- Shallow and narrow recessions
5.2.2. Classification of Benqué et al. (1983)
- U-shaped recessions, with poor prognosis
- V-shaped recessions, short or long, with favorable prognosis
- I-shaped recessions, with a good prognosis
5.2.3. Miller classification (1985)
It is for therapeutic purposes and offers predictability of results.
- Class I: the recession affects only one side of the tooth, it does not reach the mucogingival line, there is no interdental tissue loss. 100% coverage can be considered.
- Class II: recession affects only one side of the tooth, it reaches or exceeds the mucogingival line, there is no interdental tissue loss. 100% coverage can be considered.
- Class III: the recession affects only one side of the tooth, it reaches or exceeds the mucogingival line, there is loss of interdental bone and the proximal gingival tissue is apical to the enamel-cemental junction, while remaining coronal to the base of the recession, there is a malposition. Only partial coverage can be considered.
- Class IV: the recession reaches or exceeds the mucogingival line, the proximal tissues are located at the base of the recession and the recession affects more than one face of the tooth. No coverage can be envisaged.
5.2.4. Classification of Cairo et al. (2011)
A new classification of mucogingival conditions was established in 2017 by a group of experts from the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP). This classification expands and takes into account the classification established by Cairo et al. (2011), which only concerned gingival recessions. This classification was based on the depth of the recession and the loss of interproximal attachment .
∙ RT 1: gingival recession without loss of proximal attachment.
Clinical implication: Complete recovery may be predictable.
PERIODONTAL RECESSIONS ETIOLOGIES – CLASSIFICATIONS
∙ RT 2: gingival recession associated with a loss of interproximal attachment less than or equal to the vestibular recession.
Clinical implication: Complete coverage can be achieved despite interproximal attachment loss.
∙ RT 3: gingival recession associated with interproximal attachment loss greater than vestibular recession.
Clinical implication: complete recovery is not possible.
PERIODONTAL RECESSIONS ETIOLOGIES – CLASSIFICATIONS
With appropriate techniques complete recovery is possible for Cairo types 1 and 2 but remains impossible for type 3 (Miller Class IV).
PERIODONTAL RECESSIONS ETIOLOGIES – CLASSIFICATIONS
CONCLUSION
When the gum recedes and exposes part of the tooth root, we speak of gingival recession . This can cause sensitivity to cold or aesthetic discomfort. Sometimes also, when the size of the recession is significant or when the gum is too thin, the risk of aggravation increases. In the long term, too significant a recession, even without sensitivity or aesthetic discomfort, limits the precision of brushing, promotes the emergence of gingivitis and periodontitis and can result in the loss of the exposed tooth. The multifactorial etiology of the recession must be eliminated before any surgical decision. Periodontal health can be maintained with a minimal amount of keratinized gingiva. The indications for surgical treatment must be well defined in the presence of a thin biotype, aesthetic deficit, hypersensitivity and cervical lesions.
PERIODONTAL RECESSIONS ETIOLOGIES – CLASSIFICATIONS
Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.