PERIODONTAL RECESSIONS
I- Terminology and definition:
The term “gingival recession” has long been used by authors to designate root denudation following apical migration of the gingiva.
In 1983, Wilson used another term: “marginal tissue recession”, which seems more appropriate since the gingiva is not the only periodontal tissue involved in the case of recession but also the desmodont and the alveolar bone, and because the origin of the tissue initially present opposite the root surface can be mucosal (case of an ectopic tooth) or
gingival .
This term was taken up and adopted in 1996 during the last “ World Workshop in periodontaltics ” of the American Academy of Periodontology.
Marginal tissue recession is the partial exposure of the root surface such that the apex of the gingival crest lies apical to the cementoenamel junction.
II- The etiological factors of marginal tissue recession:
The etiology of recession is considered multifactorial. There are predisposing factors that represent risk factors, which will act in association with triggering factors.
1- Predisposing factors:
The bone factor:
– A periodontium with thin alveolar bone (type III and V according to the Maynard and Wilson classification ).
– Bone defects (fenestration and dehiscence).
PERIODONTAL RECESSIONS
Mucogingival factors:
– Insufficient height of attached gingiva (less than 1 mm).
– Pathological insertion of brakes and bridles.
– A shallow vestibule.
Dental factors:
– The vestibular position of the dental emergence point.
– A root diameter that is too wide.
– An absent enamel-cementum junction.
– Dental malpositions (version, rotation and egression).
2- Triggering factors:
Traumatic factors :
– Traumatic brushing.
– Occlusal trauma.
Inflammation of periodontal tissues .
Iatrogenic factors:
– A poorly adapted fixed prosthesis (unsuitable subgingival limit, excess sealing cement).
– Poorly designed hooks in partial removable prosthesis.
– Poorly polished coronal restorations.
– Poorly controlled orthodontic movement.
– A poorly located discharge incision.
– A traumatic tooth extraction.
3 – Others:
– Non-carious cervical lesions.
– Bad habits (nail biting, interposition of objects).
– Tobacco.
III- Pathogenesis and evolution of marginal tissue recession
The pathogenic mechanism of marginal tissue recession may be purely inflammatory, or it may be related to trauma. Inflammation and trauma may also play a concomitant role.
1- Inflammatory pathogenesis:
In the case of periodontal inflammation, the pocket epithelium sends digitations through the infiltrated connective tissue to reunite with the oral epithelium.
Their junction and the disappearance of the connective tissue give rise to the creation of a cleft which widens over time.
2- Traumatic pathogenesis:
Trauma to the gum causes the appearance of subclinical inflammation characterized by the formation of digitations at the level of the oral epithelium which invaginate within the connective tissue, which results in the same inflammatory pathogenic process but in the opposite direction.
PERIODONTAL RECESSIONS
3- The evolution:
It is very variable, favored by the thinness of the gingival and bone tissue. By progressing apically, the recession finds a point of equilibrium by bone thickening. A certain stability is observed in the absence of associated periodontitis.
VI- Diagnosis of marginal tissue recessions:
Marginal tissue recessions are clinically manifested by denudation of the dental roots, following migration of the gingival margin in an apical direction.
They can be single (on a single tooth) or multiple (concerning several teeth), affecting one or more faces of the tooth.
1- Measurements of recession and adjacent gingival tissue:
According to Jahnke et al in 1993, to define recession exactly, precise measurement of vertical and horizontal parameters is necessary for possible operative planning.
Vertical measurements:
– Apparent recession: corresponds to the height of the recession, measured between the enamel-cement junction to the gingival margin.
– Hidden recession: corresponds to the depth of the survey.
– The height of the keratinized tissue: measured from the gingival margin to the mucogingival line.
Horizontal measurements:
– Recession width: the widest mesio-distal distance.
– The width of adjacent papillae: is measured at their bases.
2- Clinical manifestations associated with marginal tissue recession:
Marginal tissue recession may be accompanied by:
– McCall ’s festoon : which corresponds to a reactive and non-inflammatory fibrous thickening of the residual attached gingiva.
– Stillman ‘s cleft : which corresponds to a superficial lesion of the epithelium and the connective tissue, in the form of a fissure, indicates the progression or appearance of a recession.
PERIODONTAL RECESSIONS
Examination of the exposed root surface is accomplished through the search for etiological factors (the presence of cervical striae is a sign of traumatic brushing).
3- Differential diagnosis:
Pseudorecession is an early migration of the marginal gingival margin of a tooth, compared to the gingival margin of adjacent teeth. The connective tissue attachment remains located immediately below the cementoenamel junction, so there is no root denudation.
V- Classifications of marginal tissue recessions:
1- The classification of Sullivan and Atkins in 1968:
This classification is based on the height (depth) and width of the recession, which appeared to be very beneficial with the introduction of gingival grafting techniques.
Class I: deep and wide recession.
Class II: shallow and wide recession.
Class III: deep and narrow recession.
Class IV: shallow and narrow recession.
2- The classification of Benque et al in 1983 :
U-shaped recession: poor recovery prognosis, because recessions are often broad and deep.
V-shaped recession: favorable recovery prognosis, because the banks at the base of the recession are close.
I-shaped recession: a good recovery forecast because the recession is narrow.
3- Miller’s classification in 1985 :
Miller based his classification on two criteria: the apical level of recession and the level of soft and hard tissues in the interdental space.
This classification makes it possible to establish the recovery prognosis and therefore to know the therapeutic possibilities for each class of recession
-Cl 01: the recession does not reach the mucogingival line, there is no interdental tissue loss, the coverage is 100%;
-Cl 02: the recession reaches or exceeds the mucogingival line, there is no interdental tissue loss, the coverage can be total.
These first two classes correspond to gingival recessions.
-Cl 03: the recession reaches or exceeds the mucogingival line, there is loss of interdental bone and the papillary gingiva is apical to the enamel-cement junction, while remaining coronal to the base of the recession, or there is a malposition, only partial recovery is expected;
-Cl 04: the recession reaches or exceeds the mucogingival line, the proximal tissues are located at the base of the recession, and it affects more than one side of the tooth, no recovery is expected.
These last two classes correspond to periodontal recessions (periodontal retraction)
PERIODONTAL RECESSIONS
IV- The consequences of marginal tissue recessions:
1- Hyperesthesia:
It is an increased sensitivity of the teeth to temperature variations, to the ingestion of certain foods and to contact, which makes brushing difficult.
2- Cervical caries :
They develop on bare surfaces, usually due to poor hygiene.
3- Wedge defects:
They are wedge-shaped at the exposed dental neck, appear following traumatic brushing in a horizontal direction. Can be very sensitive when deep.
4- The unsightly aspect:
Root denudation and irregular contour caused by recession in the anterior maxillary teeth is a real aesthetic problem, especially if the smile line is high.
Root coverage is indicated to meet aesthetic demands, eliminate hypersensitivity, stop the progression of recession and the worsening of these inconveniences.
PERIODONTAL RECESSIONS
Deep cavities may require root canal treatment.
Interdental brushes effectively clean between teeth.
Misaligned teeth can cause chewing problems.
Untreated dental infections can spread to other parts of the body.
Whitening trays are used for gradual results.
Cracked teeth can be repaired with composite resins.
Proper hydration helps maintain a healthy mouth.