Case Studies




Identifying and Dealing with Recession

Not all recession is bad and needs treatment, but all recession needs to be identified and labeled.  A primary role of the periodontist is to repair recession and restore inadequate zones of keratinized gingiva. It is important for dentists and hygienists to identify these issues early. Many clinicians think it is merely a cosmetic concern to be treated with veneers, crowns or fillings. However, the problem is not being addressed often only one solution is offered.

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 origin or 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 set the 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 we could 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 treatment.

Treatment Options

Pre 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 expected.

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 coverage.

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 to get 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 dental procedures. 

The bone level dictates the level of the soft tissue.  If 3 mm recession is present, 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.

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