Rethinking recession

THE SET-UP

“Gingival recession is one of the most prevalent periodontal pathologies. In this article we examine the different contributing factors to be considered for an accurate diagnosis."
-Dr. Peter O. Cabrera, team lead

Recession is commonly defined as the apical migration of the periodontal attachment. From a practical clinical perspective, most clinicians apply a visual standard in diagnosing this type of pathology. From a more detailed analysis, however, what is commonly called gingival recession is really a combination of pathologies that result in bone loss, root damage, decay and significant patient discomfort in the form of root sensitivity.

Given this variety of presentations, root exposure is a more comprehensive and descriptive term than gingival recession. I propose the term “gingival recession” be eliminated and substituted with a more comprehensive definition, which is “root exposure.” The word recession is generally misunderstood and frequently misdiagnosed, which is why clinicians need to refine and rethink how they look at it.

Diagnosing root exposure

There are many factors that can lead to root exposure (see “What causes root exposure"), from thin bone to trauma. Clinicians need to be able to spot it and diagnose it. Diagnosing root exposure should be part of a comprehensive periodontal exam and can be organized in three categories:

1. Disease evaluation. This includes probing depth, notation of bleeding on probing, the distance of the marginal tissue from the cementoenamel junction (CEJ), and root lesions whether they’re the result of trauma, abfraction or abrasive.

2. Structural evaluation. There are many structural characteristics that can predispose patients to root exposure.

• Periodontal biotype is one of the least used diagnostic criteria in periodontal evaluation, and also is one of the most useful. Periodontal biotypes are generally defined as the thick, flat periodontium and the thin, scalloped periodontium. It is in the thin biotype where the patient presents with thin bone and tissue where we are likely to see root exposure. Although root exposure also can occur in the thick biotype, depending on the clinical circumstances, it is more common in the thin biotype.

• Tooth position in the alveolar process also can be seen in structural evaluation. The more facially or lingually positioned a tooth is in the alveolar process, the thinner the bone becomes and the more likely you are to see root exposure. This can occur with normal wear and tear. Extreme labial or lingual position of the roots can place the tooth outside of the alveolar process.

3. Functional (parafunction, abrasion and restorative trauma).

• Parafunction, especially in the presence of occlusal interferences, can lead to abfractive cervical lesions.

• Abrasion, whether it is the result of aggressive brushing or it’s chemical, can lead to migration of the apical attachment as well as enamel erosion and dentin exposure.

• Restorative trauma is violation of the periodontal attachment, either in subgingival preparation or insertion of margins, and has deleterious consequences-typically in the periodontium. The result is inflammation and increased probing depths. In the thin periodontium, we tend to see apical migration of the attachment and thus root exposure.

Case presentations

In these five cases, you can see different examples of root exposure as well as cases that could be mistaken for root exposure.

Case report No. 1

Passive eruption, the migration of the attachment to the CEJ after the tooth has reached its occlusal position, occurs in all individuals. In this 9-year-old patient, there is a discrepancy between the tissues on the lateral incisors versus the central incisors (Fig. 1). This is a result of passive eruption and not true root exposure as the tissue is located at the CEJ.

Case report No. 2

A 29-year-old patient presented with a chief concern of gingival recession in the mandibular anterior segment. She was interested in implant placement in the area of No. 18. The clinical exam shows a thin periodontium with minimal zones of attached tissue. From a skeletal perspective, the CT scan reveals she has very thin bone, and the teeth have been orthodontically tipped facially, which places them outside of the alveolar housing (Figs. 2 and 3).

Case report No. 3

The patient presented with thin periodontium and teeth placed outside of the alveolar housing (Fig. 4). Tooth No. 29 shows root abrasion as well as significant decay. With the soft tissue reflected for gingival reconstruction, it becomes apparent that the amount of loss of attachment (bone loss) is much greater than what we can see visually. Periodontists often call this “hidden recession,” as this attachment loss is not clearly visible.

Case report No. 4

Violation of the attachment during a restorative procedure resulted in apical migration of the attachment and root exposure in a thin biotype (Fig. 5).

Case report No. 5

What appears to be extensive recession is principally a result of abfraction or abrasion. Soft-tissue reconstruction in this case would be indicated in localized areas only. There is generally adequate attached tissue, and when compared with the teeth that have no root exposure, this patient’s needs are much more occlusal and restorative than they are periodontal (Figs. 6 and 7).

Finding it early

Root exposure is about bone loss and root damage, and is a more appropriate term than simple gingival recession. The analysis and diagnosis of root exposure needs to be part of a comprehensive periodontal exam. The importance of early diagnosis and recognition of predisposing factors cannot be overemphasized.

Dr. Peter Cabrera received his Bachelor of Arts degree from Northwestern University and his DDS from the University of Illinois and completed his periodontal residency at Northwestern University Dental School. He lectures nationally and internationally, has a private practice in Chicago and is an affiliate attending at The Children’s Memorial Hospital. To learn more about his practice, visit perioimplantchicago.com.

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