KEY WORDS Learning objectives author

Gingival recession, aetiology, • To understand why gingival Paul Baker

mucogingival, periodontal plastic recession develops and how Specialist in Periodontics
PerioLondon, 4 Queen Anne Street
surgery, aesthetic dentistry can affect its progression
• To consider the management
strategies for gingival recession
and to understand what intervention
is possible and why this may be
indicated

PAUL BAKER
Prim Dent J. 2019;8(4):40-47

Gingival Recession –
causes and management
ABSTRACT
Gingival recession of varying extent and severity is increasingly encountered
in general dental practice. This paper outlines the aetiology of recession and
discusses management strategies, both conservative and complex. It also
highlights when to intervene and what outcomes may be expected.

Introduction of Periodontal Disease in Man’, Löe and

Gingival recession is defined as the co-workers looked at the prevalence of
location of the marginal tissues apical gingival recession in a highly dentally
to the cemento-enamel junction1. Whilst motivated population, compared to a
this might seem an obvious statement, cohort that did not have access to dental
recession does vary in how it presents, care2. In both groups, recession started
both in extent (the number of sites affected) in early adult life and the prevalence
and severity (amount of recession that has increased with age, with 90% of the
occurred). Accordingly, the significance dentally motivated population showing
to the patient may also be different. Figure signs of some recession by the age of
1 shows a patient with a small amount of 50. The distribution of the recession,
Figure 1: A patient with a small labial recession associated with the upper however, differed. In the dentally
amount of labial recession right central incisor. This is of no health motivated group, the recession affected
issue to the patient, but may present an predominantly buccal sites, with little
Figures: Copyright © 2020 Paul Baker. Reproduced with permission

undesirable aesthetic situation for someone interproximal recession being noted.

with high expectation. Alternatively, Figure In the untreated group, there was a
2 shows advanced generalised recession greater tendency towards interproximal
following successful management of a and circumferential recession. This does
generalised periodontitis. This has led suggest that there may be different
to a significant aesthetic compromise for aetiological factors involved in the
the patient, but is also associated with development of gingival recession.
sensitivity, food impaction after eating,
and speech changes as air escapes Aetiology of
through the anterior teeth. These issues gingival recession
are all the result of what the clinician We often talk of patients who have
would consider successful treatment. a thick gingival tissue biotype versus
Figure 2: Advanced generalised a thin gingival tissue biotype. This is
recession following successful The development of gingival recession the anatomical presentation of their
management of a generalised is not an inevitable consequence of age, genotype. Patients with a thin tissue
periodontitis but it is to a degree a reflection of some biotype obviously have a more delicate
pathological change. As part of his type of gingiva that will be more
seminal series on ‘The Natural History susceptible to developing recession.

40 p r i m a r y d e n ta l j o u r n a l
 a beagle dog study, which showed that
whilst there may be more clinical signs of
inflammation in sites without keratinised
tissue, the underlying histologic
inflammation was the same5. The current
belief is that treating for the sole purpose
of increasing the width of keratinised
tissue cannot be justified. The decision
to treat should be based on the status of
the tissues and the ability or not to control
inflammation.

Any trauma to the oral tissues can cause

gingival recession, but a thin gingival
tissue biotype is more likely to be prone
to recession. A traumatic overbite in a
severe Class II division 2 occlusion can
Figure 3: A CT cross section in Figure 4: Alveolar cause recession on the lower labial or
a patient with clinically normal dehiscences present upper palatal tissues of the incisors,
anatomy and no recession over the root surfaces or both. The presence of a tongue
or lip stud increases the likelihood
of developing localised recession
When looking at a cross section of keratinised tissue was needed to maintain associated with the lower anterior teeth.
the dento-alveolar anatomy of an upper gingival health after it was observed that The lingual recession associated with a
central incisor, it can be seen just how areas with less than 2mm of keratinised tongue piercing is of particular concern
thin the labial alveolar bone is over an tissues exhibited persistent signs of clinical as there are no proven techniques for
upper central incisor. Figure 3 shows inflammation4. This was later disproved by correcting recession defects in this area.
a tracing over a CT cross section in a
patient with clinically normal anatomy Gingival recession and
and no recession, showing just how periodontal disease
thin the labial alveolar bone is. In patients with a thin tissue biotype,
overzealous cleaning can traumatise
The tissues may be further compromised the gingiva enough to cause labial
by the presence of an alveolar recession (See Figure 5). However, in
dehiscence3, where there is a lack of these patients, insufficient cleaning will
alveolar bone over the root surface. lead to localised inflammation that the
The rest of the supporting structures tissue is too delicate to withstand and
can be expected to develop, and there this may also result in gingival recession
will, at least initially, be an overlying (See Figure 6).
mucosa and gingiva, with an inserting
ligament into the root surface from Figure 5: Overzealous cleaning The management of periodontal
the overlying connective tissue. The disease is commonly associated with the
assumption is that such an anatomical development of some gingival recession.
situation is less resilient to the stresses The probing depth reduction that
and challenges of everyday function, occurs following successful nonsurgical
and as a consequence, more prone to treatment of periodontal disease is
the development of gingival recession. a combination of gingival recession
Figure 4 shows alveolar dehiscences and attachment level gain, and often
present over the root surfaces on raising a in equal measure6. Thin tissues,
mucoperiosteal flap in a recession case. oedematous tissues and anterior teeth
can be expected to respond with more
The type of gingiva around the teeth is less recession after treatment. Obviously,
important than the quantity. Historically, Figure 6: Recession as resective periodontal surgery is going
it was felt that a zone of attached a result of inflammation to create significant gingival recession

Vol. 8 No. 4 winter 2019/20 41

 Gingival Recession –
causes and management

Figure 8: Subgingival restorative

Figure 7: Non-surgical treatment leading margins associated with persistent
to increased recession gingival inflammation Figure 9: Thin tissue biotype recession

in its attempt to ‘pocket eliminate’. This establishment of the correct anatomical

recession tends to be circumferential, relationship in a more apical position.
rather than the more localised labial In a thick tissue biotype, this will result
recession that may be seen with in bone loss and the development of
toothbrush trauma. This is relevant a periodontal pocket. In a thin tissue
because we still do not have predictable biotype recession is more likely to
corrective surgical procedures to develop. (See Figure 9).
treat the “black triangle disease” of
interproximal recession. Figure 7 shows Gingival recession
a patient who was concerned about and orthodontics
the aesthetic result of losing the papilla Whilst orthodontics does not cause
between her front teeth. Periodontal recession per se, it can influence the
examination revealed localised progression of recession. Orthodontic
periodontal bone loss that required movement within the limits of the
treatment. A course of nonsurgical alveolar housing will retain bone on
treatment reduced the pockets down to all aspects. Pushing a tooth beyond this
shallow probing depths but increased bony limit will lead to the formation of
the amount of recession. an underlying alveolar dehiscence and
the associated risk of progression. Figure
Gingival recession and 10 shows the recession in a patient
restorative dentistry who has had orthodontics to treat upper
The principle of the supracrestal tissue and lower crowding. Expanding the
attachment (biologic width) is well- arches to create room for the teeth has
established7. There may be a temptation resulted in a thin tissue biotype and
to place the margins of anterior subsequent gingival recession.
restorations in a subgingival position
to achieve an optimal aesthetic result.
The further subgingival the margin, the
harder it will be to clean, and the higher
the risk that plaque retention will elicit
an inflammatory response (See Figure
8). In a thin gingival tissue biotype,
this is likely to result in recession apical
to the restoration margin. Anything
that increases plaque retention in
this area may have this affect, such
as poor marginal fit, poor crown
emergence angles or rough restorative Figure 10: Recession in a patient who
surfaces. Invasion of the supracrestal has had orthodontics to treat upper
tissue attachment will lead to a re- and lower crowding

42 p r i m a r y d e n ta l j o u r n a l
Figure 11: Recession extended Figure 12: An associated
to the depth of the vestibule fraenal attachment

Theoretically, movement in a lingual There are two key indications for resist further progression. Knowing if
direction could lead to a reduction active intervention, if the patient has this is the case is not straightforward.
in recession if the root surface is kept aesthetic concerns, or for the prevention Certainly, the presence of persistent
clean. What is more likely, however, of continued recession. Whilst inflammation would be a risk factor
is an improvement in the local tissue surgical procedures for root surface for progression, but there are no good
type to reduce the risk of recession coverage have been advocated for the predictors for whether the recession
progressing. If labial movement is management of persistent sensitivity or has reached a stable position or is
planned in a patient with a thin tissue shallow root caries, there are clearly likely to progress. Often recession sites
biotype, then supportive maintenance less aggressive ways to manage these need to be monitored. The taking and
and control of the local factors is conditions. recording of measurements, similar to
essential. If recession develops or measuring pocket depth, is an obvious
cannot be maintained, then orthodontic Resolution of inflammation way, allowing for comparison over a
movement should be stopped and and oral hygiene instruction period long enough to allow measurable
gingival grafting may be Whether monitoring, active change. Measuring recession in this
considered. management or complex treatment is way is remarkably subjective, and an
indicated, the first stage of treatment unreliable measurement over prolonged
It should also be remembered that is to try to achieve periodontal health. periods. Clinical photographs provide
fixed orthodontic treatment may This would include the removal of a better way to detect a true change.
be accompanied by the two main any local factors, such as calculus or
aetiological factors in the formation of restoration overhangs, followed by Management for
recession, plaque retention due to the providing oral hygiene instruction to the prevention of
orthodontic hardware, or the risk of ensure and maintain an adequate level continued recession
overcompensation and developing a of plaque control. In patients with a The decision to undertake surgical
more traumatic cleaning regime. thin tissue biotype who are prone to procedures to prevent continued gingival
recession, the tooth brushing technique recession should be based on concern
The management should be ‘effective, yet atraumatic’. This that the recession has resulted in an
of gingival recession may involve ensuring that the patient area that can no longer be maintained
By the nature of the local anatomy, does not ‘scrub’ across the gingiva. A by the patient. This may be because
most gingival recession is self-limiting. softer toothbrush or sensitive head may the recession has extended to the depth
As the recession progresses up the root be required, but patients should be of the vestibule, such as in Figure 11,
surface in the maxilla, or down in the reviewed to make sure that the plaque where the patient is unable to clean
mandible, the gingival tissues tend to is being adequately removed. The properly. Figure 12 shows an associated
become thicker and therefore more absence of marginal inflammation fraenal attachment making cleaning
resilient. The decision to intervene is should indicate a consistently good difficult. The gingival tissues may just
not a clear-cut one as there are no level of dental cleaning. prove too uncomfortable of difficult for
specific predictors of sites at risk of the patient to maintain adequately.
progressing. It is often reasonable to Monitoring
give preventive advice and considering As previously mentioned, gingival In situations such as this, the aim
monitoring for progress before deciding recession often progresses to a point of treatment is to produce a robust,
whether intervention is justified. where the soft tissues are able to preferably keratinised, thicker tissue

Vol. 8 No. 4 winter 2019/20 43

 Gingival Recession –
causes and management

13a 13b 13c

Figures 13a-e: The stages 13d 13e

of a free gingival graft
in an orthodontic patient
with significant localised
recession

biotype that will allow the patient to sharp dissection (Figure 13b), then a
clean the area thoroughly. Coverage of matching sized piece of graft 1.5-2mm
the recession may be secondary factor thick is harvested from the plate (Figure
that is unimportant. Figure 13 outlines 13c). This is then secured in place and
the stages involved in a free gingival allowed to heal (Figure 13d). In the
graft in an orthodontic patient with immediate post-operative period, the
significant localised recession. A free graft survives by ‘plasmatic circulation’,
graft is one that has been removed from diffusion of the nutrients from the
its blood supply and transferred to a underlying recipient bed. Areas of graft
remote site. A recipient site is prepared over the root surface will not receive
locally by means of a split thickness much in the way of nutrients and risk

14a 14b 14c

Figures 14a-e: 14d 14e

A tunnel procedure

44 p r i m a r y d e n ta l j o u r n a l
becoming necrotic. For this reason, and smile line play a role in whether
free gingival grafts are excellent for this is noticeable. The ability to cover
producing attached, keratinised tissue recession depends on how much
apical to the recession, and creating interproximal tissue loss has occurred.
a thick, robust tissue type (Figure 13e); There are still no techniques that can
they are not good for achieving root predictably recreate lost interdental
surface coverage. papillae, but our ability to cover labial
recession is also dependent on their
This is one of a number of techniques being good interproximal tissues.
that can be used but it is out of the
scope of this article to explain the When choosing a suitable technique
decision-making process. Where for aesthetic recession coverage, the
the tissues are more robust, other decision will be based on achieving
techniques may provide the coverage a predictable high percentage of
needed to replace the tissue that post-operative root surface coverage
has been lost and produce a better and a good tissue match for colour
aesthetic result. Figure 14 shows a and consistency. For this reason,
tunnel procedure, which undermines pedicle flaps are more likely to be
the adjacent tissue to allow it to be the procedure of choice. Pedicle
moved, being used in conjunction flaps are raised from the adjacent
with a connective tissue graft. tissue and retain a blood supply to
improve the healing. Figure 15 shows
Recession coverage a coronally positioned flap being
for aesthetics raised and coronally moved down
Patients may find gingival recession the tooth to give an aesthetically
aesthetically unacceptable for a variety satisfactory result. Coronally
of reasons. Generalised labial recession positioned flaps are often used in
can create unnaturally long looking conjunction with a connective tissue
teeth, or expose root surfaces that can graft sandwiched underneath to
be of different colour to the crown of improve the tissue quality. Pedicle flap
the tooth. Recession can affect teeth to procedures can also be used to cover
varying degrees causing asymmetry. multiple recession defects in a single
Of course, the patient’s lip line at rest procedure, as shown in Figure 16.

15a 15b 15c

15d 15e Figures 15a-e:

A coronally
positioned flap

Vol. 8 No. 4 winter 2019/20 45

 Gingival Recession –
causes and management

16a 16b Where recession has affected the

interproximal tissue, the ability for
grafting procedures to work is limited. In
these cases, other restorative techniques
may be used to try to give the patient an
acceptable end result. Figure 17 shows
a patient with some scope for soft tissue
improvement to their labial recession,
but this is limited due to the presence
of interproximal loss. The patient was
Figures 16a-c: Pedicle flap procedures to 16c treated with a combination of a tunnel
cover multiple recession defects procedure with connective tissue graft
to move the tissue down and cover
as much of the recession as possible.
Sensibly placed resin composite
restorative material was then used
to optically reduce the interproximal
space and fill the abrasion cavities.

FGDP
Membe (UK)
5
rs rec
0% of eive

Dementia-Friendly all ou
r
and gu
f
stand
ards
public idance

Dentistry
ations

Good Practice Guidelines produced by FGDP(UK)

in collaboration with the Alzheimer’s Society
and other specialist organisations

available now
in print & online
Offering clear, evidence-based and practical information for dental
professionals and other care providers, the new book contains more
than 50 recommendations for practitioners, categorised using the
FGDP(UK)’s ‘ABC’ grading system.
“Dentists have a crucial role to play in the community for people with dementia.
These guidelines are an important step to helping more people live well with their condition,
and we hope that dentists across the UK will put them into practice” Alzheimer’s Society

www.fgdp.org.uk Available in print for only

£29.99 £14.99 to FGDP(UK) members
at fgdp.org.uk/shop

46 p r i m a r y d e n ta l j o u r n a l
Where the interproximal tissue loss is times, however, where gingival recession
more extensive, periodontal surgery can progress to a point where tooth loss
cannot improve it. If resin composite will occur or periodontal pocketing will
restorations can be placed to improve start to progress apically or laterally.
the aesthetic aspect, they must be done Timely intervention can often prevent
in a way that does not inhibit oral this. Clinicians should be able to assess
hygiene, as this is likely to exacerbate the presence of recession and whether
the gingival issue. In extreme cases, the marginal inflammation can be
a gingival veneer can be provided, controlled. Where there is uncertainty
either in acrylic or silicone, to give or concern, referral to a periodontics
the patient an aesthetically pleasing specialist, or a periodontics or restorative
prosthetic solution (Figure 18). dentistry consultant may be appropriate.

Conclusion There are a number of techniques that

Gingival recession is a common can surgically correct gingival recession
condition that can develop at various where it is an aesthetic concern. None
intraoral sites in people over time. Often of these procedures can provide a
it is of little consequence. There are guarantee of 100% coverage, but
they can be considered predictable
in most cases. The ability to cover will
depend on the ability to move local
tissue across the recession defect, and
also be detrimentally affected by any
interproximal tissue loss.

Figures 17: A combination of soft tissue

grafting and composites to improve aesthetics

Figure 18: Acrylic gingival veneer to mask extensive recession

references extent of gingival recession. between the width of keratinized to mechanical non-surgical
J Periodontol. 1992 Jun;63(6):489-95. gingiva and gingival health. therapy: a review. J Periodontol.
1 Proceedings of the 1996 World 3 Rupprecht RD., Horning GM, Nicoll J Periodontol. 1972;43(10):623-7. 1992 Feb;63(2):118-30.
Workshop in Periodontics. Ann BK, Cohen ME. Prevalence of 5 Wennstrom J, Lindhe J, Role of 7 Gargiulo AW, Wentz FM, Orban
Periodontol. 1996 Nov;1(1):1-947. dehiscences and fenestrations attached gingiva for maintenance B. Dimensions and relations of the
2 Löe H, Anerud A, Boysen H. The in modern American skulls. of periodontal health, J Clin Dent. dentogingival junction in humans.
natural history of periodontal disease J Periodontol. 2001;72(6):722-729. 1883;10(2):206-221. J Periodontol. 1961;32:261-7.
in man: prevalence, severity, and 4 Lang NP, Löe H. The relationship 6 Greenstein G. Periodontal response

Vol. 8 No. 4 winter 2019/20 47