Gingival Recession:Cause,Classification & Treatment

 Cervical lesions, which have been found to be present in 85% of the population, represent a major problem for dentists to restore with composite resin materials due to the varying adhesive properties of the tooth structure, the biomechanical aspects of the cervical area, and difficulties in accessing and isolating the area to be restored.^1,2 The incidence also may be higher in individuals retaining their permanent teeth, as the aging population is increasing.1 Additionally, at a time when people are maintaining their natural teeth longer, the likelihood of developing caries in Class V areas also increases.³

When Class V cervical lesions are noncarious in nature, they are classified as abfractions, with an appearance characterized by a loss of hard dental structure near the cement-enamel junction. The lesions’ shape may resemble a wedge with an inward-pointing apex.1 The cause of abfractions is thought to be occlusal stress that produces cervical cracks and, subsequently, predisposes the tooth surface to the effects of erosion and abrasion.4 Although critical literature reviews suggest that abfraction is a hypothetical component of cervical wear, it is important to determine causative factors for noncarious lesions, as treatments range from eliminating the aggravating agents to specific restorative procedures.^4,5

Gingival Recession
Typically involving at least one tooth surface, gingival recession can lead to root surface exposure at the gingival margin.⁶ This not only causes aesthetic impairment, but the fear of tooth loss, an increased susceptibility to root caries, and hypersensitivity of the dentin.6 As gingival recession is the displacement of the soft tissue margin, tooth malpositions, high muscle attachment, frenal pull, and occlusal trauma can create the conditions necessary to cause recession and root exposure.⁷ Another less obvious cause, oral jewelry, also has been linked to gingival recession.⁸ Studies have shown that piercings in the lip and tongue lead to localized gingival recession as an adverse consequence.8 In one study, individuals with tongue piercings presented an 11-times greater risk of developing gingival recession over the control group

 Noncarious Class V Lesions

As the health and appearance of gingival tissue is important to the aesthetics of a smile, many with noncarious Class V lesions and/or exposed tooth structure from gingival recession wish to have their conditions treated without the cost or inconvenience of invasive methods.²⁰ Used to treat noncarious Class V legions, glass ionomer cements, compomers, and composite resins work alone or in combination to correct the aesthetic issues and prevent further damage.¹ When unaesthetic Class V lesions display caries, a combination of glass ionomer materials for the internal aspects of the restoration and a resin-based composite material for the surface has been advocated.3 This treatment method is believed to provide aesthetic results while increasing the potential for caries reduction.³

The physical properties of resin-based composites allow a bond to tooth structure, with highly aesthetic results, so many practitioners feel that they are the best materials to use when restoring cervical defects.⁵ In a recent study, resin composite restorations that were placed to treat noncarious cervical lesions exhibited no secondary caries and far less deficiencies in marginal adaptation than compomer restorations after 3 years.²¹ There are, however, some challenges in using resin-based composites for Class V lesions.²

When placing resin-based composite restorations in the aesthetic zone, it is good to have an understanding of the composites being utilized, especially with regard to their respective optical and physical characteristics.^22,23 When used and placed properly, the polychromatic effects seen in natural teeth can be replicated.^22,23 More importantly, producing outstanding composite resin restorations is achieved thorough comprehension of natural tooth morphology and how each component of tooth structure affects aesthetics.^24,25



Resin-Based Composites and Gingival Health

In past studies, resin-based composites showed promising results for treating Class V lesions and masking the effects of gingival recession.²⁶ Through observations of composites, it was found that they do not adversely affect gingival health, and that there is typically less inflammatory response to well-finished and contoured composite resins than carious lesions that are left untreated.²⁶Another study, comparing plaque buildup around newer composite resins and conventional composites, found that there was no significant difference in plaque formation of the 2 materials.²⁷ 

Unfortunately, when composite resins are applied to teeth presenting with gingival recession, the resulting tooth-colored restorations tend to make the teeth appear very long, leading to an unaesthetic appearance.²⁷ To correct this issue, the need for resins that are gingival-colored has increased.²⁷ Manufacturers have met this demand, creating products that demonstrate the aesthetics of natural gingival tissue.²⁷ Aside from the aesthetic value of these new materials, the composites also allow for minimally invasive procedures to cover the roots and exposed tooth structure caused by the gingival recession.²⁷ 

These new resin-based composites correct the aesthetic deficits of gingival recession by framing the tooth or teeth with material in a similar pink color to the gingival tissue.²⁰ These gingival-colored composites tend to demonstrate greater color stability and resistance to wear.20 When used in collaboration with the new generation of bonding agents, which enable bonding to metal, porcelain, enamel, and dentin, gingival-colored composites have been proven to enhance the smiles of patients with gingival recession.²⁰ More importantly, this treatment option provides a clinical solution for patients that is aesthetic, economical, and practical.²⁷ 



Aesthetic Gingival Composite Resins

An aesthetic gingiva-shaded light-cured composite resin (Amaris Gingiva [VOCO America]) was recently introduced, providing practitioners with the option of correcting gingival recession with a minimally invasive and less costly procedure. This pink-colored composite (available in one translucent gingival color and 3 pink flowable opaquers that can be mixed together to better match an individual’s gingival shade) was specifically developed for indications in the cervical area, including composite restorations in gingival colors, V-shaped defects, exposed cervical areas, aesthetic corrections of the gingiva area, primary splinting, and the correction of red/white aesthetics. This restorative material also gives the clinician the ability to mask exposed crown margins to improve aesthetics and patient satisfaction. 

 A study that investigated the impact on treatment outcome after 12 months of different subgingival irrigation solutions during scaling and root planing (SRP) was recently published in the Journal of Periodontology by Dr. Carlos Krück et al. The randomized trial involved 51 adult volunteers with generalized chronic periodontitis who were treated by full-mouth SRP using the following subgingival irrigants during SRP: 0.9% sodium chloride, 0.12% chlorhexidine digluconate, or 7.5% povidone-iodine. Probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP) were recorded prior to SRP, after 3 months, and after 12 months. Subgingival plaque samples were analyzed for Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola. The study found that PD, CAL, and BOP were significantly improved in all groups after 12 months (P < .001 to P = .044). No significant differences were seen between the groups for all sites and sites with 4 to 6 mm PD at the baseline. The povidone-iodine group had the highest clinical improvements. The counts of A actinomycetemcomitans and P gingivalis were significantly reduced after 12 months (P = .045, P = .002) using povidone-iodine. Significant differences between the groups were seen after 3 months for A actinomycetemcomitans and P gingivalis, and after 12 months for T forsythia. The study concludes that no differences were seen between the groups in the clinical results after 12 months, although regarding the microbiological results, a slight benefit seems to derive from the use of povidone-iodine.

 Why Do So Many Dentists Mistrust Composite To Treat Black Triangles?

Like many clinicians, Michael’s (the patient in question) dentist in North Carolina hadn’t heard of Bioclear and was unfamiliar with injection molding of composites. Therefore he was leery of treating Michael with "bonding." At that point Michael decided to cross the country for a different solution because porcelain veneers and periodontal surgeries did not appeal to him as ideal treatments. After he saw my "Black Triangle" and "Restoratively Driven Papilla Regeneration" articles on the Internet and videos on YouTube, he opted to fly to the west coast for treatment. 
After spending many hours working with manufacturers and tens of thousands of dentists, I compiled a "top 5" list of composite and porcelain fallacies that have steered dentists away from minimally invasive composite treatments for black triangles, or has doomed their previous attempts leaving them gun-shy to try it again:

1. "Acid-etching cleans the tooth." 
   False. Phosphoric acid barely touches plaque. Biofilm is so tenacious and we forget that phosphoric acid removes the mineral, not the organic component of tooth surfaces. Biofilm is organic, not a mineral. This residual biofilm at the margins is likely the number one reason why Class V and interproximal composites turn brown at the margins. No bonding agent can bond to biofilm, and most dentists are leaving biofilm on their hard to access margins.
2. "A stronger dentin bonding agent is the answer." 
   False. They (the manufacturers) keep selling us new and improved dentin bonding agents with higher and higher dentin bond strengths. The problem is twofold; first of all, in a case like this, most dentists are bonding to plaque, calculus, and contaminated dentin and no current resin bonds to biofilm. Secondly, with an approach using the Bioclear matrix; uncut, blasted, and rinse-etched (with phosphoric acid) enamel is leveraged to provide the bulk of the retention and reliance on the dentin is lessened. We can trust enamel bonding. The key is in the design of the Bioclear Matrix and the ability to "wrap" the tooth with seamless composite jacket.
3. "A full crown is better." 
   False. If you were the patient with otherwise healthy teeth, would you choose full crowns? Consider that a full crown destroys 70% of coronal tooth volume with a 10% to 20% chance of eventual resultant pulpal death.
4. "A porcelain veneer is better than bonding." 
   In a case like this, false. First, porcelain veneers cannot reach far enough to the lingual, so the space is blocked from view but becomes a plaque trap on the lingual. Secondly, bonding a veneer to this much cervical dentin should make you nervous. Very nervous.
5. "Direct bonding is too difficult."

In the past this may have been true. But today, false. In the modern resin era, we utilize anatomic Bioclear matrices coupled with injection molding filling technique with, for example, a universal nanocomposite, thus creating and ideal a flowable/paste interlace.

CASE WORKUP
First, I consulted 2 renowned microscope-equipped periodontists. I would have normally immediately excluded the surgical option based on this patient’s situation but, in this case, because of the severity of the embrasures attrition, I felt that second and third opinions were warranted. In addition, if a follow-up surgical approach were needed, the periodontist would already be on board. 
Noted periodontist, Dr. Peter Nordlands’ summary of this patient: "Dear David, the papilla height across the lower anterior teeth is located at the same level as all of the other adjacent papillae. This means that the individual papillae are not deficient but instead, the patient has suffered incisal edge wear and extrusion of the incisors. Although root coverage could be very predictable, I would recommend a restorative solution as you have so beautifully shown in the Bioclear video. My experience is that surgical papilla reconstruction is most predictable in situations where the papilla has been surgically abused previously."

CASE PRESENTATION
Figure 1 shows the functional and aesthetic dilemma. The retracted view (Figure 2) shows the magnitude of the black triangles on the lower. The patient’s first priority was treating the lowers, and he would return to the west coast in a few months to treat the upper black triangles. Facial abrasions and recession tripled the complexity of treatment (Figure 3). Blasting, which is application of a mild abrasive with air-water mix, is an absolute necessity for this treatment (Figures 4 to 7). Once the facial abrasions are restored up to the line angle areas, a rubber dam is placed. The interproximal areas are nicely managed with the rubber dam and the DC-203 Bioclear matrices together (Figures 8 to 15). To try to treat the facial abrasions at the same time that the matrices are in position is not recommended. The Bioclear method is almost the inverse of the old flat matrix technique. The facial surfaces are left with some excess because this is the loading area. The interproximals, when molded, will require little or no finishing. Immediate postoperative views demonstrate the dramatic emergence profiles, mirror finish, and regenerated papillae (Figures 16 to 18). Dentists and periodontists often ask these patients, "Are these veneers? Are these crowns?" No. This is done with an injection molding technique performed with high-level magnification using a universal nanocomposite (in this case, 

Tufts dental researchers conducted a three-year follow-up study that examined the stability of a treatment option for receding gums and found that complete root coverage — the goal of the surgery — had been maintained. This specific tissue regeneration application, developed at Tufts, reduces the considerable pain and recovery time of gum grafting surgery.
The case study of six patients is published in the July 2009 issue of the Journal of Periodontology.
“Patients have a less invasive treatment option for receding gums and we now have evidence to support the stability of this relatively painless procedure. Instead of leaving the dental office with stitches in the roof of their mouth, a patient leaves with a small bandage on the arm that can be removed in an hour,” said Terrence Griffin, DMD, associate professor, chair of the department of periodontology, and director of postdoctoral periodontology at Tufts University School of Dental Medicine in Boston.
“One of our previous research studies showed that all of the post-operative bleeding and most of the post-operative pain were related to the gum tissue removed from the roof of the mouth for use as a graft,” he continued.
Traditional gum grafting surgery requires surgically excising tissue from the roof of the mouth (the palate) to replace the gum tissue lost around the teeth. Unfortunately, removing tissue from the roof of the mouth extends recovery time and is a major source of patients’ discomfort or pain. According to the American Academy of Periodontology, periodontal disease is the primary cause of tooth loss in adults aged 35 and older. Periodontal disease includes gum recession, also called gingival recession, which can result in tooth root decay and tooth loss.
The new tissue regeneration application from Tufts uses platelet concentrate gel applied to a collagen membrane as the graft instead of using tissue from the roof of the mouth. The graft is soaked in the patient’s platelets, using blood drawn in the same visit. Placed over the receding tooth root, the graft is then surgically secured.
In order to examine three-year efficacy of the treatment, measurements were taken from six patients in the gum recession area at baseline, 6, and 36 months after surgery. At six months, 24 out of 37 teeth from the six patients had complete root coverage (65 percent). At 36 months, 21 out of 37 teeth from the six patients had complete root coverage (57 percent). The authors said that the recession over three years was minimal and that the results are comparable to traditional gum grafting surgery.
“Our previous research determined that pain and discomfort were barriers to receiving traditional gum grafting surgery. We have also shown previously that this treatment for gum recession results in proper coverage of the tooth root, better esthetics than those found with traditional gum grafting surgery, and enhanced patient satisfaction with the results,” said co-author Wai Cheung, DMD, MS, assistant professor in the department of periodontology at Tufts University School of Dental Medicine.
Over the last decade, Griffin and his colleagues, including Cheung, have studied alternatives to traditional gum grafting surgery and have more than 20 publications on the topic.
“Gum disease affects most American adults and research is linking periodontal disease to other health problems, including heart disease. Encouraging patients to undergo surgery to fix receding gums can be difficult because the mere thought of this dental surgery is often associated with considerable pain. This treatment, while only marginally more expensive for the patient, is more time-consuming and technically more difficult for us but the end result — improved esthetics, reduced pain, and, most importantly, improved oral health for the patient — make it a valuable and important alternative,” said Griffin.