This presentation describes the gingival recession, its classifications and theories of pathogenesis and different etiological factors in its progression.

1. DR. MANISHA SINHA
II nd yr PG
DEPT OF
PERIODONTOLOGY
GINGIVAL
RECESSION
RAJARAJESWARI DENTAL COLLEGE AND HOSPITAL

2.  Introduction
 Definitions
 Classifications
 Etiology
Pathogenesis
Diagnosis
Treatment procedures
Overview and clinical studies
Conclusion

3. INTRODUCTION

4.  Recession is exposure of root surface by an apical shift in the position of gingiva.
(CARRANZA )
 Gingival Recession is defined as displacement of soft tissue margin apical to
cementoenamel junction (CEJ) with exposure of root surface. (LINDHE)
DEFINITIONS

5.  Gingival recession is defined as “the displacement of marginal gingiva apical to the
cemento-enamel junction (CEJ).”(AAP 1992).
 Marginal tissue recession is defined as the displacement of the soft tissue margin
apical to the cemento-enamel junction (CEJ). ( )

6.  Gingival recession: Defined as a situation where the gingival margin
lies against any part of the root surface of the tooth. It usually implies
recession affecting the facial aspect of a root. (Smith R G, 1997)
 Gingival recession is defined as the apical migration of the junctional
epithelium with exposure of root surfaces.[Kassab MM, Cohen RE-
2003].

7. The actual position is the level of coronal
end of the epithelial attachment on the
tooth,
The apparent
position is the level of the crest of the
gingival margin

8. Actual recession. The actual
recession is shown by the position of
the attachment level. The “receded
area” is from the cementoenamel
junction to the attachment.
Visible recession. The visible recession
is the exposed root surface that is visible
on clinical examination. It is seen from the
gingival margin to the cementoenamel
junction

9. CLASSIFICATIONS

10.  Sullivan and Atkins (1968)
 • Mlinek (1973)
 • Liu and Solt (1980)
 • Bengue (1983)
 • Miller (1985)
 • Smith (1990)
 Nordland and Tarnow (1998)
 • Mahajan (2010)
 • Cairo et al. (2011)
 • Rotundo et al. (2011)
 • Ashish Kumar and Masamatti
(2013)
 • Prashant et al. (2014).

11. Deep-Wide
Deep-Narrow
Shallow-Wide
Shallow-Narrow

12.  Shallow narrow: Recession <3 mm
 Deep wide: Recession >3 mm.

13. Visual recession is measured from
the cemento-enamel junction to the
soft tissue margin.
Hidden recession refers to the loss of
attachment within the pocket, i.e.,
apical to the tissue margin.

14. According
to the
root
coverage
prognosis
"U" type—poor prognosis
"V" type—fair prognosis
"I" type—good prognosis.

15. Miller has primarily based his classification of gingival recession defects
on two aspects:
 [1] Extent of gingival recession defects and
 [2] Extent of hard and soft tissue loss in interdental areas
surrounding the gingival recession defects.

18. LIMITATIONS
1. Difficulty in locating MGJ
2. No information about keratinized tissue and its
components.
3. Class III and IV recession, the interdental bone or soft
tissue loss is an important criterion to categorize the
recessions. The amount and type of bone loss have not
been specified.
4.. The cases, which have interproximal bone loss and the marginal
recession that does not extend to MGJ cannot be classified either in
Class I because of interproximal bone or in Class III because the
gingival margin does not extend to MGJ
4. From the prognostic standpoint, Classes I and II cannot
be distinguished from each other as they both anticipate
100% root coverage

19. 5. As regards Class III, partial root coverage is anticipated while
some recent studies demonstrate that root coverage can be
unpredictable in treating Class III recession-type defects.
6. No identification for class III and IV if no adjacent teeth
present.
7. Miller’s classification does not specify facial (F) or
lingual (L) involvement of the marginal tissue.
8. Recession of interdental papilla alone cannot be
classified according to the Miller’s classification.
9. Classification of recession on palatal aspect is another
area of concern

20. Smith in 1990
 to assess both vertical and horizontal extent of the defect.
 The degree of horizontal component was expressed as a value ranging
from 0 to 5 depending on the severity of CEJ exposure, while the vertical
extent of the recession was measured in millimeters using a periodontal
probe on a 0–9 range

23. DRAWBACK
the author proposed that
in cases of extensive vertical component, further horizontal
component may be allotted at an intermediate distance between
CEJ and base of the defect, which is not clearly specified.

25. Class I: GRD not
extending to the
MGJ.
Class II: GRD
extending to the
MGJ/beyond it.
Class III: GRD
with bone or soft-
tissue loss in the
interdental area up
to cervical 1/3 of
the root surface
and/or
malpositioning of
the teeth.
Class IV: GRD
with severe bone
or soft tissue loss
in the interdental
area greater than
cervical 1/3rd of
the root surface
and/or severe
malpositioning of
the teeth.

26. • BEST: Class I and Class II
with thick gingival profile.
• GOOD: Class I and Class
II with thin gingival profile.
• FAIR: Class III with thick
gingival profile.
• POOR: Class III and Class
IV with thin gingival profile.
PROGNOSIS

27. DRAWBACK
 This modification still does not accommodate all clinical conditions. For
example, a tooth with gingival recession not extending up to MGJ but
with interdental soft and hard tissue loss can neither be placed in Class I
nor in Class III since there is no mention of the involvement of MGJ in
Class III.

28.  Recession Type 1: Gingival
recession with no loss of
interproximal attachment.
Interproximal CEJ was clinically
not detectable at both mesial and
distal aspects of the tooth

29. Recession Type 2:
 Gingival recession associated with
loss of interproximal attachment.
 The amount of interproximal
attachment loss (measured from the
interproximal CEJ to the depth of the
interproximal pocket) was less than or
equal to the buccal attachment loss.

30. Recession Type 3: Gingival recession associated with loss of inter-
proximal attachment.
 The amount of interproximal attachment loss (measured from the
interproximal CEJ to the depth of the pocket) was higher than the
buccal attachment loss (measured from the buccal CEJ to the depth
of the buccal pocket)

31.  Specific variables considered :
1. The amount of keratinized
tissue (KT = 2 mm)
2. The presence/absence of
noncarious cervical lesion
(NCCL)
3. With a consequent
unidentifiable CEJ
4. The presence/absence of
interproximal attachment
loss
Method of assessment:
A. KT ≥2 mm
• NCCL – absent
• Interproximal attachment loss –
absent.
B. KT <2 mm
• NCCL – present
• Interproximal attachment loss –
present.

32. • KT ≥2 mm – no NCCL – no interproximal attachment loss (AAA)
• KT ≥2 mm – NCCL – no interproximal attachment loss (ABA)
• KT ≥2 mm – no NCCL – interproximal attachment loss (AAB)
• KT ≥2 mm – NCCL – interproximal attachment loss (ABB)
• KT <2 mm – no NCCL – no interproximal attachment loss (BAA)
• KT <2 mm – NCCL – no interproximal attachment loss (BBA)
• KT <2 mm – no NCCL – interproximal attachment loss (BAB)
• KT <2 mm – NCCL – interproximal attachment loss (BBB).

33.  This classification can be applied for facial surfaces of maxillary teeth
and facial and lingual surfaces of mandibular teeth.
 Interdental papilla recession can also be classified according to this
new classification.
 Class I deals with marginal tissue recession with no loss of interdental
bone or soft-tissue.
 Class II and III deal with the loss of interdental bone/soft-tissue with/
without marginal tissue recession.

34. There is no loss of interdental bone or soft-
tissue.
This is sub-classified into two categories:
Class I-A: Gingival margin on F/L aspect lies apical to
CEJ, but coronal to MGJ with attached gingiva
present between marginal gingiva and MGJ.
Class I-B: Gingival margin on F/L aspect lies at or
apical to MGJ with an absence of attached gingiva
between marginal gingiva and MGJ.
Either of the subdivisions can be on F or L aspect or
both (F and L):

35. The tip of the interdental papilla is located between
the interdental contact point and the level of the CEJ
midbuccally/ mid-lingually. Interproximal bone loss is visible on
the radiograph.
This is sub-classified into three categories:
Class II-A: There is no marginal tissue recession on F/L aspect.
Class II-B: Gingival margin on F/L aspect lies apical to CEJ but
coronal to MGJ with attached gingiva present between
marginal gingiva and MGJ.
Class II-C: Gingival margin on F/L aspect lies at or apical to MGJ
with an absence of attached gingiva between marginal gingiva
and MGJ

36. The tip of the interdental papilla is located at or
apical to the level of the CEJ mid-buccally/mid-lingually.
Interproximal bone loss is visible on the radiograph.
This is sub-classified into two categories:
Class III-A: Gingival margin on F/L aspect lies apical to CEJ, but
coronal to MGJ with attached gingiva present between
marginal gingiva and MGJ.
Class III-B: Gingival margin on F/L aspect lies at or apical to
MGJ with an absence of attached gingiva between marginal
gingiva and MGJ.

37. The position of interdental papilla remains the basis of classifying gingival
recession on palatal aspect.
 The criteria of sub-classifications have been modified to compensate
for the absence of MGJ.
 PR-I deals with marginal tissue recession on palatal aspect with no
loss of interdental bone or soft-tissue.
 PR-II and PR-III deal with the loss of interdental bone/soft tissue with
marginal tissue recession on palatal aspect.

38. Palatal recession-I
 There is no loss of interdental bone or
soft-tissue.
 This is sub-classified into two categories:
 PR-I-A: Marginal tissue recession ≤3 mm
from CEJ.
 PR-I-B: Marginal tissue recession of >3
mm from CEJ.

39. Palatal recession-II
 The tip of the interdental papilla is located
between the interdental contact point and
the level of the CEJ mid-palatally.
Interproximal bone loss is visible on the
radiograph.
 This is sub-classified into two categories:
 PR-II-A: Marginal tissue recession ≤3 mm
from CEJ.
 PR-II-B: Marginal tissue recession of >3
mm from CEJ

40. Palatal recession-III
 The tip of the interdental papilla is located
at or apical to the level of the CEJ mid-
palatally. Interproximal bone loss is visible
on the radiograph.
 This is sub-classified into two categories:
 PR-III-A: Marginal tissue recession ≤3 mm
from CEJ.
 PR-III-B: Marginal tissue recession of >3
mm from CEJ.

41. Prashant et al. (2014)

42. PREVALANCE
• Increases with age, 8% in children to 100% in adults over 50 yrs
• Tooth malpositioning and traumatic brushing
Woofer 1969
• prominent on mandibular 1st premolar and canine
• As width of KG decreased percentage of recession increased
Stoner 1980
• Predominantly found on buccal surfaces
Serino 1994

43. Epidemiological
studies show that
more than 50% of
subjects in the
populations
studied have one
or more sites with
recession of at
least 1 mm,
buccal sites being
most commonly
affected.
Higher levels of
recession have
been found in
males than
females..
Recession at the
buccal surfaces is
common in
populations with
good oral hygiene
(Serino et al.,
1994;) whereas
with poor
standards of oral
hygiene it may
affect other tooth
surfaces (Baelum
et al., 1986).
Gingival
recession at the
lingual surfaces of
lower anterior
teeth showed a
strong association
with the presence
of supragingival
and subgingival
calculus (van
Palenstein
Helderman et al.,
1998).

44. ETIOLOGY
 Calculus.
 Tooth Brushing
 High Frenal Attachment.
 Position of the Tooth
 Tooth Movement by Orthodontic Forces
 Improperly Designed Partial Dentures.
 Smoking.
 Restorations.
 Chemicals.

45. Predisposing
factors
Inadequate attached
gingiva
Malpositioning of teeth
Osseous dehiscence or
thin facial plate
Precipitating
factors
Vigorous brushing
Laceration
Recurrent inflammation
Iatrogenic factors

46. C. Bruckmann and G. Wimmer

47. PATHOLOGICAL FACTORS

48. ANATOMICAL FACTORS
.
One etiologic factor that may be associated
with gingival recession is a prior lack of
alveolar bone at the site [Watson PJ-
1984].

49. PHYSIOLOGICAL FACTORS
Orthodontic movement of teeth to
positions outside the labial or lingual
alveolar plate, leading to dehiscence
formation.
[Wennström JL, Lindhe J, Sinclair F,
Thilander B-1987].

50. Direct trauma from malocclusion
 Class II Div 2 malocculusion
 Reduced overjet
 Retroclination of upper anterior teeth.

51. Chemical trauma
 Topical cocaine application can cause gingival erosion.

52. TRAUMA
1. vigorous toothbrushing,
2. aberrant frenal attachment,
3. occlusal injury,
4. operative procedures and tobacco
chewing
Clinical and case report studies also have associated gingival
recession with chronic trauma, including habits such as chronic
impaction of foreign bodies within the gingiva or gingival injury.
(Jenkins WM, Allan CJ-1994).

53.  Traumatic mechanical tooth brushing is a factor in the etiology of gingival
recession. Recession due to tooth brushing was characteristically
localized on facial surfaces and frequently “V” shaped, often occurring in
association with tooth abrasion. [Gillette WB, Van house RL.-1980]
 Epidemiologic studies have supported the idea that traumatic tooth
brushing may be associated with gingival recession, with buccal gingival
recession noted more frequently on the left side of the jaw. [Addy M,
Mostafa P, Newcombe RG-1987].

54. ABERRANT FRENAL ATTACHMENT
 Some studies did not find any correlation between frenal pull and recession
[Trott JR, Love B-1966] whereas others did find an association [Parfitt GJ,
Mjor JA-1964].

55. Stillman’s clefts:
 A narrow triangular shaped recession.
 As the recession progress apically, the cleft
becomes broader exposing the cementum of the
root surface
 When the lesion reaches muco-gingival junction
the border of the oral mucosa is usually inflamed
because of the difficulty in maintaining adequate
plaque control at this site.

56.  Rolled, thickened band of gingiva
 usually seen adjacent to the cuspids when
recession approaches MGJ.

57. Periodontal disease
 Bone destruction will occur in periodontitis
alongwith loss of connective tissue attachment and
apical migration of the junctional epithelium.
 The resulting attachment loss may be expressed
primarily as pocket deepening or as gingival
recession.

58. Partial denture
 Poorly designed have the potential to
cause gingival recession by
 Direct trauma to gingiva
 By acting as plaque retentive factor

59. Restorative dentistry
 Subgingival restoration
margins can cause plaque
accumulation and gingival
inflammation and alveolar
bone loss

60. Smoking
 Direct relationship
 Etiology could be due to altered
immune response
 Additional tooth brush abrasion
from oral hygiene practise.
 More prevalent in smokeless
tobacco and in mandibular
buccal area.

61. Trauma
induced
Bacteria
induced

62. Mechanism of gingival recession-Baker and
Seymour
 Histological changes during an induced recession.
 3 stages of GR
Initial stage
Second stage
Third stage

63. subclinical inflammation
Clinical inflammation and proliferation of
rete pegs
Increased epithelial proliferation resulting
in loss of connective tissue core
Merging of epithelium and resulting in
separation and recession of gingival
tissues.

64. Inflammation of the connective
tissue of free gingiva and its
consequent destruction, where
the gingival epithelium migrates
into the connective tissue and
gets destroyed.
Here the gingival epithelial
basement membrane and sulcus
epithelium reduce the thickness
of the connective tissue between
them, thus reducing the blood
flow by impairing the repair of
the initial injury.
As the lesion progresses, the
connective tissue disappears
and fusion occurs between the
gingival epithelium and the
sulcular and union epithelia,
which will subsequently withdraw
due to lack of blood flow

65. Sensitivity
pain from
exposed
dentine,
Yellow
appearan
ce of
roots
Stained
teeth
Susceptibili
ty to
decay- root
caries.
Long teeth-
poor
esthetics
Spaces
between
the teeth
Food
lodgement.

66.  The denuded root surfaces cause deterioration in the esthetic
appearance, dentin hypersensitivity, and inability to perform proper oral
hygiene procedures (Zucchelli et al., 2006; Seichter, 1987).

67. 1. Exposed root surfaces are susceptible to caries.
2. Abrasion or erosion of the cementum
Underlying dentinal suface
Sensitivity
3. Hyperemia of pulp may also result from excessive exposure of root
surfaces.
4. Interproximal recession creates oral hygiene problems & resulting
plaque accumulation

68. CONCLUSION

70. • Carranza’s Clinical periodontology – 9th & 10th ed
• Clinical Periodontology and Implant Dentistry – Jan Lindhe 5th ed
• Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA. Root
coverage procedures for the treatment of localised recession-type defects (Review). The
Cochrane Library 2009, Issue 2
• Umberto Pagliaro, Michele Nieri, Debora Franceschi,Carlo Clauser,and Giovanpaolo Pini-
Prato. Evidence-Based Mucogingival Therapy. Part 1: A Critical Review of the Literature
on Root Coverage Procedures. J Periodontol May 2003
• The etiology and Prevalence of gingival recession – Moawia M.Kassab, Rober E. Cohen
– JADA Feb 2003
• The use of free gingival grafts for aesthetic purposes Paulom. Camargo, Philip R.Melnick
& E. Barrie Kenney : Periodontology 2000, Vol. 27, 2001,
• Decision-making in aesthetics: root coverage revisited - Philippe bouchard, jacquesmalet
& alain borghetti - Periodontology 2000, Vol. 27, 2001

71.  THANK YOU