Gum recession is a pathological condition characterized by a decrease in the volume of the gum in the direction of the apex with the exposure of the neck and root of the tooth. The main complaints are reduced to the appearance of an aesthetic defect. With disease, there is an increased sensitivity of the teeth, the risk of developing root caries increases. The diagnosis is based on the patient’s complaints, anamnesis data, the results of physical and X-ray examination methods. Depending on the form and local status, the treatment can be carried out conservatively or surgically.
Meaning
Gum recession – apical migration of marginal gum. Among the total number of periodontal diseases accompanied by loss of dental epithelial attachment, disease is detected in 10% of periodontal patients. In childhood, the frequency of root exposure is about 8%, whereas in people after 45-50 years, characteristic signs of marginal gum deficiency are found in almost every patient. There is evidence that in economically developed countries, the prevalence of gum recession is higher compared to countries with a low standard of living, which is explained by the high frequency of orthodontic treatment. The risk of gum recession is determined by the ratio of two main indicators – the width of the attached gum and the size of the free gingival margin. If these indicators are equal, the probability of a gum recession reaches 90%. Dentists consider the optimal ratio to be 5:1.
Causes
Gum recession is a polyethological condition, which in most cases is a symptom or consequence of another pathological process. Traumatization of the gingival margin during improper brushing of teeth is considered one of the main causes of local gum recession. The application of excessive pressure when performing horizontal movements leads to damage to the vestibular plate of the canines located in the dentition with a buccal tilt. Since the blood supply to the thinned cortical part of the bone is carried out due to the blood vessels of the periosteum, traumatization of the latter leads to ischemia of this zone, as a result of which there is a decrease in bone tissue along with a decrease in the height of the gum.
Pathology is often detected with a deep bite, dysocclusion in the anterior area, which is explained by the uneven distribution of masticatory pressure. The lack of load on the tooth, as well as its overload, negatively affects the condition of the marginal periodontal. The shallow vestibule of the oral cavity in combination with the small size of the keratinized gum and the lack of expression of the equators of the teeth contribute to the development of gum recession, since during chewing food is freely pushed in the direction of the marginal gum, further injuring it. Crowding of dentition, massive muco-epithelial strands, high attachment of bridles, protrusive position of teeth – all these anatomical features also increase the risk of gum recession.
Symptomatic gum recession occurs in inflammatory, inflammatory-destructive or dystrophic periodontal diseases. In chronic periodontitis, periodontal disease, along with the loss of bone tissue, there is a deficit of marginal gum. Perforation of the root of the tooth, violation of the rules of intraligmental anesthesia, deep preparation of the ledge, damage to the dental epithelial junction by the edge of the crown, overhanging edges of fillings, forced orthodontic treatment methods – all these factors of iatrogenic origin are also capable of causing local gum recession. Overestimation of the bite height when restoring the chewing surface of the tooth with a photopolymer, tab or crown leads to the appearance of supracontact – a point of increased chewing pressure. As a result, compression processes occur in the marginal gum, bone remodeling with a predominance of the osteoclastic component. A decrease in the height of bone tissue is accompanied by a gum recession.
Classification
There are 4 main classes of gum recession in dentistry:
- It is characterized by a deficiency of free loose gums. There are no pathological changes in the interproximal areas.
- Clinically, there is an apical displacement of the attached gum. The height and structure of the bone of the interdental septa are not disturbed.
- It is combined with a slight apical migration of the gingival margin of the approximal surfaces.
- It is characterized by a circular loss of bone and gum along the entire circumference of the tooth and in the interdental spaces.
According to the prevalence, gum recession is divided into localized and generalized, according to etiology – into traumatic, symptomatic and physiological.
Symptoms
With gum recession, patients indicate local or generalized root denudation. Palpation determines the thickening of the marginal gum, resembling a roller. Clinically, gum recession can be in the form of a thin slit – degeneration or a V-shaped defect – fenestration. There is an increased sensitivity of the teeth. With symptomatic gum recession that has developed against the background of periodontitis, the dentist reveals hyperemic edematous (with an acute process) or cyanotic pasty (in the chronic course of the disease) mucosa, periodontal pockets. Uneven apical migration of the gum is observed, the level is higher on the oral side in the area of the lower incisors and the upper first molar, that is, in places of increased tartar deposition. In periodontal disease, generalized uniform gum recession is observed. Inflammatory phenomena, periodontal pockets are absent. Wedge-shaped defects are found in the neck areas.
Gum recession is the main complication during orthodontic treatment using non-removable techniques. The use of excessive forces in combination with the small width of the attached gum leads to thinning of the vestibular cortical plate, deficiency of the marginal periodontal. Due to the unsatisfactory level of hygiene in orthodontic patients, signs of gingivitis and periodontitis are also detected. When the root or bottom of the tooth cavity is perforated, the dentist, along with the gum recession, detects a fistula course with bulging granulations. The vertical percussion is positive, which indicates the presence of a destructive process of bone tissue around the pathological focus.
Diagnostics
Diagnosis of gum recession includes clinical and radiological examination. When assessing the local status, the width and depth of the gum recession, the fullness of the interdental gap, the integrity of the dental epithelial junction, the width of the keratinized gum and the area of the attached keratinized gum, the periodontal biotype are determined. All these indicators are extremely important both for assessing the severity of gum recession and for choosing a rational treatment plan. When the depth of the apical migration of the gingival margin is up to 3 mm, a slight degree of gum recession is indicated, a value within 3-5 mm indicates an average severity of the pathological process. The exposure of the roots by more than 5 mm is interpreted as a severe degree of recession. The presence of a decrease in the tissues of the interdental gap signals 3-4 degrees of severity of gum recession. When detecting insufficient width of the zone of the attached keratinized gum and a thin biotype (thickness less than 1.75 mm), both the depth and thickness of the tissues are restored.
Local recession of the gum of traumatic origin is detected, as a rule, only from the buccal side. At the same time, a decrease in the height of the interdental septa and the destruction of the cortical plate within 1-2 teeth are determined on the X-ray. With symptomatic generalized gum recession, vertical or horizontal bone resorption (depending on the course of the inflammatory process), osteoporosis, and destruction of the cortical plate are diagnosed on an X-ray. The bleeding index (PBI) is positive, which indicates the development of an inflammatory process in periodontal tissues. The Fedorov-Volodkina hygiene Index confirms the presence of dental deposits. When gum recession is detected, differential diagnosis is carried out between physiological, traumatic and symptomatic forms. The patient is examined by a dentist.
Gum recession treatment
Treatment of gum recession can be carried out not only conservatively, but also surgically. In the absence of complaints from the patient about increased sensitivity of the teeth and the presence of an aesthetic defect, the therapy of apical gum displacement includes training in hygiene rules (special attention is paid to the choice of oral care products), elimination of soft and hard subgingival and supra-gingival deposits, control of occlusive contacts. If the gum recession is observed in the area of the tooth covered with a crown, in the presence of overhanging edges and signs of violation of the marginal fit, reprosthetics is indicated. With symptomatic generalized deficiency of the marginal gum, anti-inflammatory treatment of the underlying disease is carried out.
Hypersensitivity of the teeth, patient complaints about the presence of an aesthetic defect are indications for surgical intervention. The restoration of the marginal gum can be performed using single-layer and double-layer methods of closing the recession, as well as the method of directed tissue regeneration. Optimal local conditions for surgery to eliminate gum recession are a deep vestibule of the oral cavity, sufficient thickness and width of the keratinized gum zone, thick periodontal biotype.
Elimination of etiological factors that caused the displacement of the marginal gum apically, dental deposits, meticulous observance of hygiene rules – all this stabilizes the level of the gingival margin in local gum recession. The prognosis for symptomatic generalized marginal gum deficiency depends on the success of treatment of the underlying disease. The creation of a keratinized zone contributes to the spontaneous complete closure of shallow local recessions of the gum. Unstable prognosis in the postoperative period is noted with the formation of a long epithelial attachment, which is often a consequence of complicated healing of the wound surface.
