Gingival Recession (Receding Gums)

Introduction:

Esthetic dentistry remains the biggest challenge for dentists all over the world. They face the daunting task of treating gingival recession, also called receding gums, which refers to root visibility partially or totally. Patients often report at a very later stage when the prognosis becomes poor. It is commonly seen that the gingival recession affects almost every individual. It is usually treated when it causes either dentinal hypersensitivity or root caries. Certain strategies have been proposed to treat gingival recession, which includes graft surgeries and, in addition, some adjunctive combinations to them. It could be the greatest boon if patients show greater concern for the treatment of gingival recession at an early stage to prevent the extraction of teeth.

What Is Gingival Recession?

Gingival recession is defined as exposure of the root surface by an apical migration in the position of the gingiva. It means it goes down, and the root, which is otherwise covered with gingiva, is totally or partially visible. It has four classes (Miller PD -1985), and among them, Class I and Class II have 100 percent complete coverage and excellent prognosis, while class III and IV have partial coverage and poor prognosis. Hence, the best time to have treatment or this biggest hurdle of esthetic dentistry is class I and class II gingival recession. At this time, very little sensitivity is there, and even there are very few chances of root caries.

It is a good fortune that esthetic surgery has developed a lot of plastic surgery procedures to treat gingival recession. They are broadly classified as either rotational flaps or autogenous grafts.

• Autogenous grafts involve taking a graft from the donor site and placing it into the recipient site, with both sites located at different positions.
• Rotational flaps involve placing the graft coronal or lateral to the donor site. Here the recipient site is either coronal or lateral to the original site.

Nowadays, certain adjuncts are used to increase the successful outcome, which includes platelet concentrates and membranes like Chorioallantoic Membranes (CAM). The word graft refers to a piece of tissue that is transplanted from one site to another site. They can be autograft (same individual), allograft (different individual but same species), or xenograft (different species).

What Are the Signs and Symptoms of the Gingival Recession?

• Pain near the gum line.
• Sensitivity to heat and cold.
• Sensitivity during brushing, flossing, and dental cleaning.
• When the gum recession is left untreated, it can result in other severe conditions such as bone loss, tooth mobility, and tooth loss.

What Are the Causes of the Gum Recession?

• Brushing too aggressively.
• The buildup of dental plaque.
• Periodontal issues.
• Trauma to the gum tissue.
• Misalignment of the tooth.
• Smoking.
• Piercing of lip and tongue.

How Is the Gingival Recession Diagnosed?

The dentist diagnoses the gingival recession during regular dental checkups by measuring the extent of gingival recession in each tooth using a periodontal probe. Bone loss is also a common symptom of gum recession, so the dentist also measures the periodontal pocket around each tooth.

How Is the Gingival Recession Treated?

The treatment of gingival recession depends on the underlying cause of the condition. Mild gum recession can be corrected non-surgically through

• Topical antibiotics.
• Dental bonding.
• Orthodontics.

Gum Graft Surgery: Gum graft surgery is performed to completely cure gum recession. In this procedure, a gum graft is used to replace the gun tissue that is missing.

What Are the Types of Grafts Available?

Autogenous Grafts:

• Among autogenous grafts, the first and most ancient graft is the free gingival graft. It is a graft taken from the palate (best site) and transplanted into the recipient site (where there is a gingival recession). It has the best advantage of increasing the width of keratinized tissue, which, in turn, prevents the further progression of recession. However, it has two main disadvantages, namely,
• The creation of painful post-operative wounds at the palate.
• Poor matching of esthetics. In other words, the recipient site does not show good blending with adjacent tissues. Blood supply is sometimes compromised with this graft.

So, to compensate for the disadvantages of a free gingival graft, a subepithelial connective tissue graft (SCTG) came into force. It is considered a gold standard for treating gingival recession because it offers many advantages like good blending, less painful post-operative wounds, and increased keratinized tissue. But, there is only one disadvantage it requires the palate to be almost three to four millimeters thick otherwise procedure cannot be done. Also, being a technique-sensitive procedure, it is difficult to perform compared to free gingival graft (FGG).

Rotational Flaps:

• To compensate for the disadvantages associated with autogenous grafts, rotational flaps came into existence. These flaps can be moved laterally (side direction) or in coronal (upward direction). Coronally advanced flap (CAF) refers to the coronal movement of the flap, while lateral pedicle flap refers to the lateral movement of the flap. Lateral pedicle flap (LP) is indicated in anterior teeth where a large donor tissue (from the adjacent tooth) can be moved out to the recipient site. It also prevents further development of a recession by increasing the keratinized tissue and provides good esthetics. There are two more variants called,
• Transposition flap.
• Double papilla flap.

They have some disadvantages. Hence, the coronally advanced flap is better than these flaps. It provides good color blending and eliminates the need for donor and recipient tissue. It is used in single and multiple recessions and in combination with free gingival graft and subepithelial connective tissue graft (bilaminar technique). The only disadvantage associated with it is vestibular shallowing in lower teeth.

Another variant is the semilunar coronally advanced flap, which does not use any sutures also. It is the most atraumatic technique among all graft surgeries. The only limitation of this technique is at least three millimeters of keratinized gingiva are present in the tissue.

Many adjuncts are used in combination with these grafts. Such as:

Emdogain: A derivative containing an enamel matrix. It is used as an adjunct to coronally advanced flaps in treating moderate recession. However, cost remains the crucial factor for its less widespread use.

Guided Tissue Regeneration (GTR): It is the oldest adjunct among all options. It is used as a membrane beneath the coronally advanced flap. The membrane could be resorbable (Vicryl) or non-resorbable (poly-tetra fluoro ethane). It is specially indicated with deep recessions of four to five millimeters. However, the major problem with the procedure is a poor adaptation to the root convexity.

Adaptation to the root remains a challenge for clinicians. It is appreciated to note many membrane boxes have been devised to adapt the membrane to the root surface.

Allografts: Autologous concentrates like platelet-rich plasma (PRP) and platelet-rich fibrin have been extensively used in providing recession treatment. Both these platelet-rich concentrates have enormous growth factors like platelet-derived growth factor (PDGF) and vascular endothelial growth factor (VEGF). The main advantages associated with these concentrates are an increase in keratinized tissue, good healing, and increased tissue thickness. Even the blood supply is also increased due to growth factors. Besides recession treatment, they are used in extraction sockets and implant surgeries to motivate healing.

Nowadays, the combination of a coronally advanced flap with PRF is extensively used. Many other membranes are available like alloderm, mucograft, oxycell, chitosan, and collagen membranes. Alloderm is sometimes considered a good replacement for SCTG because of its good coverage. However, the thickness of keratinized tissue remains a limiting factor for Alloderm and other above-mentioned adjuncts.

Conclusion:

Recession treatment remains a stone in the success of esthetic surgery. Its eradication lies not only in the hands of clinicians but also in patient’s cooperation. Early diagnosis remains the key to success. A variety of procedures are available, but the best approach is the least trauma, maximum root coverage, and further prevention.