Recession is the loss of
attachment measured from the CEJ to the gingival margin.
Recession and inadequate amounts of keratinized or
attached gingiva are major forms of periodontal disease;
almost more prevalent than bacterial induced periodontal
disease. Recession and mucogingival defects are
considered non-pocketing periodontitis and more damaging
and unappealing than traditional periodontal disease.
Many assume it only appears
the facials of the teeth, but it can be on any surface
of the tooth. Typically recession is associated with
thin tissues where the attached gingiva is no longer
sufficient. Thin tissue can be genetic in
manufactured by ortho, trauma, desquamative gingivitis
or systemic diseases. Other contributing factors are
tooth position, frenum position, decay, braces,
restorative dentistry, habits, and genetics. Attrition
and abrasion also contribute to recession.
We are all genetically
predisposed to a certain biotype based on our lineage.
Tooth eruption or trauma may alter
these biotypes, but
the basic groundwork is genetic. The types of
dentitions with respect to the periodontium and gingival
structure are broken down into two basic biotypes:
thin, scalloped and thick, flat. These biotypes
stage for future issues.
If we evaluate and make adjustments to the foundation of
the mouth prior to beginning any
other type of dentistry then
manage and perhaps eliminate
many problems, including ones we sometimes create.
A person with a thin biotype
has highly scalloped bone. This is the interproximal
height of bone closest to the tooth’s contact point and
measured to the apex point on the mid-root of the tooth.
It determines the height of the scallop and the overall
shape of the bone. This bone is normally very flat
and tapered to a thicker plate the farther apical you
go. You could say that it goes into a knife-edged
ridge at the junction of the bone and root surface
closest to the CEJ. Figure 1 and 2
are example of a thin biotype mouth. The
difference is in
figure 1 it was identified very early.
Notice the prominent roots and almost transparent tissue
with easily identified capillaries. Figure 2
demonstrates a thin biotype with no preventative
gingival restoration and a great amount of her
foundation was lost.
A person with a thick
biotype has very thick bone which appears flat across
the CEJ and in relationship to the CEJ. The height
of contour of bone measured is very short with very
little curve. There is normally a ledge of bone on
the facial at the crest. Having a thick biotype
doesn’t give you a free pass for optimum health because
problems may present in this situation. Figure
3 is an example of
thick biotype. The teeth
appear short because the CEJ is below the gumline and
the bone is thick protruding facially and meets the CEJ.
The patient has 6-7 mm probing depths in the posterior
teeth. This situation is not a bacteria issue but
an anatomical one. If no osseous surgery is done
it will become a bacterial issue.
People with a thick biotype,
tend to have less recession and thicker tissue overall.
These people should have some reduction of tissues prior
to any type of cosmetic dentistry in order to give them
a nicer overall appearance and healthy future. Many
severe problems will be created if this issue is not
identified prior to extensive restorative work. Be
aware of the thick biotype so as to not create problems.
Thinner tissue has more
recession type attachment loss, whereas a thick tissue
will have more bacterial induced pattern to its type of
bone loss. Therefore, younger patients often
display this recession type defect due to biotype more
than older people do. Many times with a young
patient, child or teenager, there are early signs of
recession or thin tissue. This is when preventative
grafting should be done to stabilize their mouth for the
long term. Knowing the problem helps determine the best
and Post Pictures Description
Patient is 35 years
old and had previous grafting procedures done. At
his evaluation appointment his tissue presented
very thin with significant recession. Full mouth
grafting was completed with Allograft. The tissue
matured and gained good thickness and restored
root coverage. Due to the extensive recession in
some areas 100% root coverage is not to be
Treatment of thin tissue is
the most important area. Thickening the tissue before
recession occurs or when it starts is very easy to do.
The lower anterior is the most common area to graft.
Lower premolars are a very close second due to genetics
and the way our mouths are formed. If everyone had
thicker tissue, restorative dentistry would work better,
look better, and stand up to the longer term issues of
wear and tear much better than thin tissue.
Not all recession is bad and
needs to be treated and not all recession treatment.
Not all recession is fixed with grafting. There are
several techniques to fix recession and thin tissue but
not all periodontists use them. Before referring your
patient, choose your periodontist carefully for optimum
results. For every situation, there are a number of
different techniques, and for every different technique,
there are many ways to do them.
There are many gingival
grafting techniques used to repair and restore thin
tissue and recession. The first predictable technique
is the free gingival graft, which not only
increases the tissue thickness but can get root
coverage. The connective tissue graft uses
tissue from the patient’s mouth or a donor source.
These can be done alone or with pedicle flaps.
Pedicle flaps alone can also be successful.
Guided tissue regeneration helps maximize root
Donor tissue, like
Allograft, is a much kinder way to treat recession
defects. Allograft is a material taken from the same
species but placed in someone else. Basically human
donor tissue is used in place of harvesting tissue from
the roof of the mouth. We use donor graft material on
about 95% of my patients. This material is perfectly
safe. Patients cannot get diseases, reject the tissue or have any adverse reactions. The procedure is quite fast
and minimally involved, with minimal pain.
Transplanting graft material to the area is the most
common method but where it comes from has changed over
the years. The palate has been the most common location
tissue, but it is the most dreaded part of the
procedure. The palate is good, but it isn’t the only
option available! Using the palate limits how
much can be repaired at one time.
We know thicker zones of
keratinized gingiva around a tooth, makes a better
tooth. Increasing the tissue thickness, even in someone
who doesn’t have recession, is very important to
recognize and treat early. The sooner the treatment,
the more stable the tissue will be long term.
“The tissue is the issue,
but the bone sets the tone!” Is a famous quote in
the dental world. The bone level sets up the foundation
so the tissue receives nutrients and has a job to
do. Without the bone, the tissue has little to do.
The biologic width requires that there be separation of
foreign objects (i.e. restorative margins) and the bone
level, and if not the bone will dissolve until it gets
what it wants.
One of the most troubling
items of Periodontics is the number of Mucogingival
defects that go undiagnosed or unidentified. These
defects create some very difficult problems, yet they
easily overlooked until it is too late. Early diagnosis
and treatment of Mucogingival defects around teeth or
implants can lead to much better oral health and easier
The bone level dictates the
level of the soft tissue. If 3 mm recession is
count on an additional 3 mm of bone loss. Most likely
there is more. Like in Figure 3, if the bone is
thick, with a ledge at the CEJ, then you will have a
thicker band of tissue in the way.
A typical scenario, a
patient walks in and wants veneers across her front
teeth, because she has a gummy smile. You think,
just trim a bit of tissue with my laser and prep her
teeth and she’ll be great. It would be perfect for
about 6 months then
everything would fall apart.
The lab did everything right
and the color is perfect, but 6 months later
she has inflamed margins
and a red line around the tissue. What could
have happened? First rule out oral hygiene because
it was never an issue
before, so it shouldn’t be now. Rule out systemic
disease because her
health history shows no complications. It wasn’t
the tissue height, but the bone height and its
relationship to the tissue. Most likely bone
thickness may have played a
part too. What she really needed was hard tissue crown
lengthening where the bone was not only raised more apically and away from the CEJ but also thinned out
before the veneers were prepped. Pay attention to the
bone and the biological width, it is often ignored.