Non Surgical Management Of Gingival Recession

Non Surgical Management Of Gingival Recession

Dr Harshavardhan Patwal

Contents IntroductionClassification & etiological factors of gingival recessionClinical significance of gingival recessionDecision making Non Surgical management Periodontal managementOrthodontic management Esthetic dentistry Prosthodontic managementConclusionReferences

Introduction Gingival recession is defined as the exposure of the root surface by an apical shift in the position of the gingiva (Newman et al 2006).Gingival tissue recession from the root surface is a great concern for the patients.Recession of the gingival margin results in impaired esthetics and sometimes hypersensitivity.

ClassificationSullivan and Atkins (1968)Shallow narrow

Deep narrow

Shallow wide

Deep wide

Class IMarginal tissue recession which does not extend to the mucogingival junctionNo periodontal bone loss in the interdental area100% root coverage

Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13

5Miller, in 1985, classified marginal tissue recession by combining the 4 Sullivan and Atkins classifications into his 1st 2 classifications and then adding a 3rd and 4th classification. He indicated that the presence of interdental bone loss, soft tissue loss, or extruded teeth make it impossible to place a free gingival graft at the CEJ, making it impossible to obtain complete root coverage.

Based on this classification, 100% root coverage can be anticipated in Class I and Class II. All four of Sullivan and Atikins morphological categories (shallow-narrow, shallowwide, deep-narrow and deep-wide) fall within these two classes.

Class IIMarginal tissue recession which extends to or beyond the mucogingival junctionNo periodontal loss in the interdental area100% root coverage

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Class IIIMarginal tissue recession which extends to or beyond the mucogingival junctionBone or soft tissue loss in the interdental area or malpositioning of the teeth, preventing 100% root coveragePartial root coverage

7In Class III recession, partial root coverage can be expected. The amount of root coverage can be determined presurgically using a periodontal probe. The probe is placed horizontally on an imaginary line connecting the tissue level on the mid-facial of the 2 teeth on either side of the tooth or teeth exhibiting recession. Root coverage can be anticipated to that level.

Class IVMarginal tissue recession which extends to or beyond the mucogingival junctionSevere bone or soft tissue loss in the interdental area and/or malpositioning of teethNo root coverage

8In Class IV recession, root coverage is not anticipated although occasionally it can be obtained. Usually, however, root coverage is not attempted.

DETERMINANTS FACTORSCO FACTORSBacterial PlaqueO`Leary et al found direct correlation between the increase of plaque index ad the increase of marginal tissue recessionTrauma from toothbrushingImproper techniqueWrong toothbrushIatrogenic FactorsAmalgam or prosthetic overhangClampsOrthodontic appliancesHabitsFingernails or any foreign object

Tooth MalpositionBuccally displaced teeth or rotated tooth due to altered tooth-bone relationshipUnfavorable AnatomyHigh frenum insertionShallow buccal fold that produce tension on the marginal gingivaOrthodontic Movements

Clinical significance of gingival recessionEsthetic improvementCervical root defectsRoot sensitivityRoot caries.

The treatment of gingival recessions aims at 11

Surgical or non surgical therapy (Dersot,2005)If the periodontal recession is not a progressing process and it does not provoke any tooth sensitivity or esthetic problem or in case of erupting teeth in children, tooth brushing instructions and regular surveillance through a maintenance program would be the best treatment.

But if the periodontal recession is regularly progressing, and if the patients complain is a high thermal sensitivity and/or a compromised esthetic appearance, then surgical root coverage will be the best treatment.

Surgical therapyCoverage of the exposed roots is one of the objectives of periodontal plastic and reconstructive surgery.

Various mucogingival procedures have been used successfully resulting in root coverage.

These procedures increase the width of the attached gingiva and the vestibular depth & thererby counteract the tension of abberabt frenum.

Gingival recession at single or multiple sites can create gross esthetic discrepancies.Although grafting procedures have been used and improved over many years , some patients may not be prepared to undergo such treatment if they have hypersensitivity problems and their recession is only esthetic.Mucogingival success is limited withfrequent recurrence of the problem, excessive cost and time commitment considerable patient discomfort and unpredictability of the final result.Because full regeneration of the gingival tissue does not generally occur ,covering the area or concealing the exposed root by may be possible.In such cases alternative esthetic treatment is applicable.

Non surgical management

Periodontal management Orthodontic management Esthetic dentistry Prosthodontic management

Periodontal management

Only a palliative relevance in terms of the goal of complete root coverage. In other words, a coverage of exposed root surfaces cannot be achieved, and if it can, then only incipiently. On the other hand, non-surgical treatment can hinder the advance of a periodontal recession and limit the potential damage.

Non-surgical treatment alone, however, has only 18

The non-surgical treatments for recession include:Desensitizing toothpastes. Desensitizing agents. Scaling and Root planingPolishing (Aimetti et al,2005)

There are several toothpastes against tooth sensitivity, with agents such as sodium chloride or potassium salts that block the creation or transmission of the pain sensation. Fluoride gels, resins and other desensitizing agents can be applied by the dentist directly to the exposed areas of the teeth and roots, providing immediate sensitivity pain relief.

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Orthodontic management

Orthodontics may also be used to correct gingival recession, as conditions such as cross-bites and occlusion are seen as causes. By using orthodontic appliances to correct the abnormalities in bite and occlusion, studies have shown that gingival recession can be stopped and, many times, reversed. These results, however, are typically created through multidisciplinary approaches and not merely with orthodontic treatment and appliances. Seehra J, Fleming PS, 2009

Orthodontic intrusionBurstone 1977 first described Intrusion mechanics for orthodontic tooth movement.

Force values for the anterior teeth ranges from 8 to 50 g. Weiland FJ,1996

Esthetic dental therapy

The health and appearance of gingival tissue play an essential role in esthetics. The esthetic function of the tissue is enhanced when it frames the restoration. Recent advances in esthetic dental material and bonding technology have made stronger and longer-lasting composite restorations possible. The latest generation of dental bonding agents allows effective bonding of composites to dentin. Although bonding is less invasive than crowns, the latter can achieve superior esthetic correction when full coverage is indicated.

These new resin-based composites correct the aesthetic deficits of gingival recession by framing the tooth or teeth with material in a similar pink color to the gingival tissue. These gingival-colored composites tend to demonstrate greater color stability and resistance to wear. When used in collaboration with the new generation of bonding agents, which enable bonding to metal, porcelain, enamel, and dentin, gingival-colored composites have been proven to enhance the smiles of patients with gingival recession. Zalkind M, Hochman N.1997More importantly, this treatment option provides a clinical solution for patients that is aesthetic, economical, and practical.

The new composites are more color stable and wear resistant and the latest generation of dental bonding agents allows the bonding of composites to dentin various metals and porcelain.do not adversely affect gingival health, and that there is typically less inflammatory response to well-finished and contoured composite resins Blank LW, 1979

Preoperative

Shade tabs were used to determine the shade of flowable composite (Amaris Gingiva [VOCO America]). View of the selected shades that were placed.

A slight bevel preparation After the bevel preparation was made, a single-step, self-etching adhesive

The adhesive was light-cured. After light-curing the adhesive, light Opaquer was applied and then light-cured.

Sulcular anatomy was created using the Nature shade of the gingival composite.Sculpted and light-cured.

The surface texture of the restorations was refined using an ultrafine yellow flame diamond bur View of the final surface texture that was refined with the diamond bur.

View of the restorations after finishing and polishing.

An unfilled resin surface sealant (Easy Glaze [VOCO America]) was applied to the restoration.The surface sealant was light-cured.

View of the final restorations after application and light-curing of the surface glaze.

The final restorations. the gingival zeniths of teeth symmetrical and at equal heights.)

PrePost

Prosthodontic management

Gingival replacement prostheses have historically been used to replace lost tissue when other methods (e.g., surgery or regenerative procedures) were considered unpredictable or impossible. With this method, large tissue volumes are easily replaced.Tissue replacement prostheses may be used to replace tissue lost through surgical gingival procedures, trauma, ridge resorption or traumatic tooth extraction. From a prosthodontic point of view, restoration of these areas can be accomplished with either fixed or removable prostheses.

Materials used for gingival prostheses include pink autocure and heat-cured acrylics, porcelains, composite resins thermoplastic acrylics, silicone-based soft materials.

Gingival veneers

A gingival veneer is a cosmetic replacement for missing gum tissue.Uncorrectable generalized gingival recession when unsightly and visible may be masked by a gingival veneer made out of pink acrylic and made to resemble gingival tissue. It should not be worn at night and must be kept free of plaque to avoid it causing gingivitis in the underlying gingivae.The underlying periodontal condition should be rendered stable before a gingival veneer is considered.

Flexible Gum Veneers

The accepted material has been denture acrylic, and some fine aesthetic results have been made. However, the hard veneers were impossible to be made further distal than the canines because of undercuts and they could also rub and further damage the delicate gingiva.

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man presented with phonetic problems,as well as unanticipated expectoration during speech. Thepatient had recently undergone periodontal surgery, whichresulted in the loss of the papilla between the 2 maxillarycentral incisors (Fig. 1).The patient was not interested in an additional surgicalprocedure to reconstruct the papilla. Previous bondingprocedures had been performed by other dental practitionersin attempts to reduce the interproximal space and thusto improve esthetics and phonetics, but the results had beenless than ideal. In accordance with the patients wishes, aremovable prosthesis was planned.44

This type of prosthesis has limitations. Retention may be difficult, and because of the inherent porosity of the silicone-based material, staining and plaque accumulation may be a problem. Another concern is the possibility of inhalation or ingestion of the prosthesis during function.This type of prosthesis therefore requires regular maintenance and occasional revision.

Conclusion There is re-emergence of research in the role of non-surgical treatments for gingival recession defects .Given the focus placed on conservative therapies in modern dentistry, it is crucial for dentists to be aware of the risks and benefits of the no treatment option for all conditions that they are presented with.Nevertheless, it is a reliable form of therapy for patients with limited recession, and for patients who want to avoid extensive, invasive dental surgery. These methods may be a minimally invasive alternative treatment method for gingival soft tissue loss, providing esthetic results and patient satisfaction.

References Clinical periodontology,10th edition ;Newman ,Takei , Klokkevold , Carranza.Critical decisions in Periodontology , 4th edition;Walter B.HallA Critical Evaluation of Methods for Root M. Goldstein, L. Brayer and Z. Schwartz,CROBM 1996 7: 87Decision-making in aesthetics: root coverage revisited, P. Bouchard et al; Periodontology 2000, Vol. 27, 2001, 97120When not to perform root coverage procedures; Jonathan L.Gray; J Periodontol 2001, 72: 1010-12The use of porcelain laminate veneers & aremovable gingival prosthesis for a periodontally compromised patients:J Prosthetic Dent 2005

Seehra J, Fleming PS, DiBiase AT. Orthodontic treatment of localised gingival recession associated with traumatic anterior crossbite. Aust Orthod J. 2009;25:76-81. Kassab MM, Badawi H, Dentino AR. Treatment of gingival recession. Dent Clin North Am. 2010;54:129-140. Gi n g i val Prostheses A Review Izchak Ba rz i l a y, DDS, Cert ProsthoJ Can Dent Assoc 2003; 69(2):748Alternative method of conservative esthetic treatment for gingival recession M.Zalkind J Prosthet dent 1997 77 561-563

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