SHORT REPORT

State of the science on cogciety of Europe 2013

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interproximal areas [1]. Gingival recession is reported to side the alveolar bone has been reported as a risk factor

Johal et al. Progress in Orthodontics 2013, 14:16http://www.progressinorthodontics.com/content/14/1/16followed by a 5-min open discussion. Each presentationBarts and the London School of Medicine and Dentistry, Turner Street,Whitechapel, London E1 2AD, UKincrease in both severity and prevalence with age, withgreater than 90% of adults aged 50 years and above dem-onstrating its presence [2]. The labial aspect of the man-dibular incisors and maxillary molars is being mostfrequently affected [3]. The aetiology is incompletelyunderstood and thought to be multifactorial in nature,with both predisposing and precipitating factors impli-cated. The former constitutes anatomic and morpho-logical characteristics, such as alveolar bone dehiscence,thin buccal mucosa, crowding, presence of aberrant

for gingival recession [5], others have found no such as-sociation [6,7].Thus, the aim of the day was for a panel of experts to

evaluate the current evidence base in relation to eitherthe beneficial or detrimental effects of orthodontic treat-ment on the gingival tissue.

MethodThe format of the day was that the morning sessionconsisted of a number of interrelated presentations, byleading clinicians from both within the Society and aninvited guest speaker (Professor Anton Sculean),* Correspondence: a.s.johal@qmul.ac.ukCentre for Oral Growth and Development, 5th Floor, Institute of Dentistry,enamel junction and can affect the labial, lingual and/orFindings: The Angle Society of Europe devoted a study day to explore the evidence surrounding thesecontroversies. The aim of the day was for a panel of experts to evaluate the current evidence base in relation toeither the beneficial or detrimental effects of orthodontic treatment on the gingival tissue.

Conclusions: There remains a relatively weak evidence base for the role of orthodontic treatment and gingivalrecession and thus a need to undertake a risk assessment and appropriate consent prior to the commencement oftreatment. In further prospective, well designed trials are needed.

Keywords: Gingival recession; Orthodontics treatment

FindingsIntroductionGingival or soft tissue recessions are defined as the dis-placement of the marginal tissue apical to the cemento-

fraenula and ectopic tooth eruption. Precipitating factorslead to an acceleration of the defect, such as traumatictooth brushing and piercing [4]. Controversy exists inthe literature between the role of orthodontic treatmentand gingival recession. Whilst, movement of teeth out-orthodontic therapy and(a report of the Angle Someeting)Ama Johal*, Christos Katsaros, Stavros Kiliardis, Pedro Leitand Bjrn Zachrisson

Abstract

Background: Controversy exists in the literature betweenWhilst movement of teeth outside the alveolar bone hashave found no such association. 2013 Johal et al.; licensee Springer. This is anAttribution License (http://creativecommons.orin any medium, provided the original work is pMarco Rosa, Anton Sculean, Frank Weiland

he role of orthodontic treatment and gingival recession.en reported as a risk factor for gingival recession, othersOpen Access

ntroversial topics:ingival recessionOpen Access article distributed under the terms of the Creative Commonsg/licenses/by/2.0), which permits unrestricted use, distribution, and reproductionroperly cited.

Johal et al. Progress in Orthodontics 2013, 14:16 Page 2 of 5http://www.progressinorthodontics.com/content/14/1/16raised a number of questions for further discussion inthe afternoon breakout sessions.The afternoon session involved the ASE members

forming into seven breakout groups and an appointedchair, with each group being assigned to address one ormore questions arising from the morning presentations.Each breakout group chair presented back to the wholegroup their conclusions during the final session of theevening. As the findings in relation to each questionwere addressed, a very interactive whole group discus-sion followed and consensus viewpoints sought.The day was summarised, and a number of conclu-

sions reached.

Aetiology, classification, epidemiology and need fortreatment of gingival recessionThe presentation focussed not only on the aetiology,classification, epidemiology and need for treatment butalso highlighted the indications for treatment, whichcould include aesthetic concerns, hypersensitivity andthe need to improve oral hygiene. The benefits ofMiller's classification of gingival recession werepresented in terms of permitting an evaluation of prog-nosis to be undertaken [8]. The importance of optimalplaque control and aesthetics with complete root cover-age were highlighted as the treatment goals.

Orthodontic treatment and gingival recessions: what isthe evidence from animal experimental studies?The presentation highlighted the limited scientific qual-ity of research to date, with studies being confined tosmall numbers of either dogs or monkeys. The evidencein relation to the effect on the gingival tissues of movingteeth in the following manner was presented: outside thecortical plate and the observed changes with and with-out moving the teeth back. It appeared that moving theteeth outside the cortical plate and retaining them inthis position resulted in loss of both bone and soft tis-sues. Whilst moving them back to within the alveoluswas accompanied by a variable (up to 50%), gain in bonebut no soft tissue benefit was observed.

Orthodontic treatment and gingival recessions: what isthe evidence from clinical studies?The benefit of using light controlled orthodontic forcesto promote favourable gingival tissue and bony changesin particular intrusion and extrusion were highlighted.The findings from the systematic review by Joss-Vassalliet al. [9] were presented, which demonstrated a weakevidence base (with studies being retrospective in natureand of low-to-moderate value of evidence), weak meth-odology, short-term follow up and a significant number

of confounding variables, which were not controlled for.The authors reported contradictory results regarding apossible statistically significant correlation between inci-sor proclination and subsequently resulting gingival re-cession and recommended caution in interpreting thefindings. Evidence linking incisor decompensation inClass III malocclusion and the importance of the man-dibular symphyseal anatomy were highlighted, in con-junction with identifying potential risk factors.

Aspects on the envelope of the lower anterior alveolarprocess: incisor proclination by orthodontic means ordistraction osteogenesis?The concept of an alveolar envelope was proposed,within which the teeth should be maintained. The cor-tical bone of the alveolar process was considered to bethe anatomic border of this envelope. Thus, the prospectof alveolar distraction in the anterior region wasdiscussed as a means of transporting the alveolarprocess with the teeth, creating better conditions toavoid recessions. This was evaluated in a comparativecontrolled longitudinal study of orthodontic treatmentalone versus orthodontic treatment in conjunction todistraction [10]. Overall all groups demonstrated an in-crease in clinical crown height and a variable degree ofgingival recession over the follow-up period, no matter ifthe proclination was achieved with pure orthodontics orby means of destruction. No definable value of incisorproclination leading to gingival recession could be iden-tified. However, severe proclination appeared to be con-tributory. It appeared that respect for the bony envelopealone was not sufficient to avoid recessions. The import-ance of the soft tissue envelope could be considered inthe future as a contributing factor.

Gingival recession in orthodontics: a clinical matterThe importance of early correction of any observed det-rimental effect on the gingival tissues or alveolar boneduring orthodontic treatment, through a combination ofappropriate root torque and optimal patient oral hy-giene, was highlighted. In addition, the need to identifyany risk factors, such as tissue biotype and the thicknessof the alveolar bone was also emphasised to minimisegingival recession. The large individual variation of thesoft tissue following inappropriate orthodontic move-ments, such as dento-alveolar expansion and derotationwas highlighted, as well as the value of orthodontic in-trusion and correction of the traumatic occlusion, inaddition to the effectiveness/efficiency of interceptivetreatment during the mixed dentition in guiding the cor-rect eruption of the permanent teeth into the periodon-tal envelope.The development of gingival recession during or after

orthodontic treatment would be a significant clinical

problem. This not only highlights the need to undertakea risk assessment before treatment is commenced, with

2. Eliminate potential causes of recession (piercing,

Johal et al. Progress in Orthodontics 2013, 14:16 Page 3 of 5http://www.progressinorthodontics.com/content/14/1/16appropriate consent, but also to be aware during treat-ment for signs of recession. In particular, a baseline lineassessment of the gingival margin heights in addition tothe patient's age, biotype, planned arch expansion andthe width of the alveolus should be taken into accountprior to commencing treatment. Gingival recession oc-curring after orthodontic treatment has the potentialfor causing aesthetic or psychological concerns andhypersensivity. These concerns relate directly to the ageof the patient, as they are likely to be progressive in na-ture, and the severity of gingival recession in terms ofthe long-term prognosis of the tooth in question.A number of predisposing and precipitating factors are

considered important identifiable risk factors for gingivalrecession in relation to orthodontic treatment [11]. Pre-disposing factors include: anatomical and morphologicalcharacteristics, such as alveolar bone dehiscence, gin-gival biotype, skeletal pattern, narrow symphysis andectopic tooth eruption or morphology. Precipitatingfactors lead to an acceleration of the defect, such astraumatic tooth brushing, traumatic overbite, age, smok-ing, parafunctional habits, pregnancy and piercing. Inaddition and perhaps equally important are inappropri-ate treatment mechanics, such as arch expansion, withexcessive proclination and the use of RME in adult pa-tients. Care should also be taken when decompensatinga class III incisor relationship in preparation for surgeryand aligning ectopic/transposed teeth. One could con-sider the acronym ABEF to help take into account therisk factors:

A: Anatomy of the alveolar bone and proximity of theroot to the cortical plates

B: BiotypeE: Environment (oral hygiene, habits, poor brushing,

poor orthodontic mechanics, active lingual retainers)F: Functional matrix

It is equally important to recognise that a number oforthodontic procedures, such as the judicial use of den-tal extractions, interproximal enamel reduction, correctroot torque, selective grinding and if indicated treatmentin the mixed dentition can act to retain the roots withinthe alveolar bone and thereby reduce root prominenceand the risk of gingival recession. They may also allowcreeping attachment and, if planned, a better future sur-gical site. Thus, amongst the reported benefits of ortho-dontic treatment in relation to gingival recession are asfollows:

1. Self-maintaining oral hygiene2. Crown alignment within the dento-alveolar envelope

3. Removal of occlusal trauma4. Root alignment within the bonesmoking, traumatic toothbrushing)3. Avoid uncontrolled dento-alveolar expansion and

maintain arch form4. Customise bonding and mechanics5. Modify tooth anatomy whenever indicated6. Consider segment arch mechanics7. Create space before using it and use it wisely8. Consider atypical extractions, e.g. compromised

teeth9. Avoid jiggling because it may cause periodontal

problems10.Treat early (interceptive procedures and treatment in

mixed dentition)11.Re-educate the patient in their oral hygiene

technique after the end of treatment.

Development of gingival recessions in the post-orthodontic treatment periodThe recent findings of a series of retrospective studiesdesigned to evaluate the long-term effect of orthodontictreatment on labial gingival recession 5 years post-treatment were presented. Change in lower incisor in-clination did not affect the development of labial gingivalrecession [12]. Retainer type was not an influencing fac-tor in labial gingival recession, but age at the end oftreatment was the greatest predictor [13]. When com-paring a group of orthodontically treated patients to amatched untreated control group, the proportion of sub-jects with recessions was consistently higher in treatedpatients than in untreated subjects. In orthodonticallytreated patients, lower incisors seem to be the most sus-ceptible to the development of labial gingival recession[14]. The possible development of gingival recession due5. A hopeless tooth is not a useless tooth - the value ofa periodontal opinion is important, as such teeth canbe utilised to enhance bone and/or soft tissueanatomy before insertion of implants

To minimise the risk of gingival recession and maxi-mise the benefit of the orthodontic treatment, the ortho-dontist must be aware of the risk factors identifiedabove, and it is time that we, as professionals, take intoaccount more than just the crown but perhaps more im-portantly the roots and their proximity to the corticalplates. Thus, the mechanics or treatment modalities thatcould be employed to minimise the risk of recession in-clude the following:

1. Maintain good oral hygiene throughout orthodontictreatment and identify potential risk factorsto active multistranded lingual retainers was discussedin light of current findings [15,16].

Johal et al. Progress in Orthodontics 2013, 14:16 Page 4 of 5http://www.progressinorthodontics.com/content/14/1/16Indications for increasing soft tissue thickness prior toorthodontic treatmentA treatment protocol for managing patients with gin-gival recession was presented, in which, ideally furtherincisor proclination should be avoided. However, inpatients requiring pre-surgical decompensation, pre-prosthetic preparation or where a non-extractionapproach is judged as necessary: the importance of en-suring optimal oral hygiene and using a free gingivalgraft prior to the planned orthodontic tooth movementshould be considered. The preferred approach in thesesusceptible patients should be to again ensure optimaloral hygiene, align the roots within the alveolar envelope,avoiding proclination and to re-evaluate the need for amucogingival graft after treatment.

Treatment of gingival recession: state of the artThe presentation identified the following general factors,which influenced treatment outcome: tooth (crownmorphology), soft tissues (biotype), bone morphology(presence or absence of interproximal bone), environ-ment (smoking) and defect size (deeper >5 mm andwider >3 mm defects being associated with more diffi-cult root coverage). A number of specific surgical con-siderations were also identified as being important tosuccess: flap thickness ( 1.1 mm), post-surgical positionof the gingival margin (the higher the better) andmaintaining a stable flap under low tension provided op-timal wound healing. The importance of using biologicalagents (e.g. enamel matrix derivative or EMD) in con-junction with flap surgery was shown to be beneficial.The use of a modified coronally advanced tunnel flap ap-proach in treating gingival recession was demonstrated,with the advantage of optimising tissue blending andaesthetics.Unfortunately, objective information evaluating in

which patients soft tissue augmentation should beperformed before orthodontics is absent. However, thepresence of dehiscence or fenestration is suspected; twopotential options exist: avoid over-expansion of the arch,i.e. attempt to maintain the teeth within the dento-alveolar envelope by considering dental extractions orinterproximal enamel reduction. In situations where weabsolutely need to expand orthodontically out of the en-velope, it would be wise to ask for soft tissue augmenta-tion prior to treatment.In terms of what is the best method(s) for recession

coverage, there is a need to distinguish between singleand multiple recessions. In respect of single gingival re-cession, a number of options exist for recession cover-age, an EMD (Emdogain) with or without a connectivetissue graft in conjunction with a coronally positioned

flap [17,18]. Good long-term (5 years) outcomes havebeen reported with connective tissue grafts and acoronally advanced flap [19]. Alternative methods in-clude the envelope technique with connective tissuegraft [20] or the laterally positioned flap with or withoutconnective tissue graft. In the case of multiple reces-sions, the modified coronal advancement flap with orwithout graft is preferred in the maxilla [21], whilst inthe mandible, its use in conjunction to a connective tis-sue graft should be considered [22]. In regard to theMiller's class III defect, the modified coronal advance-ment tunnel technique with connective tissue graftshould be considered [22]. Whilst a free gingival graftcan be used in both single and multiple gingival reces-sions, it is associated with high morbidity due to graftremoval from the palate and sometimes necrosis of thegraft. A frenectomy can also be considered. The import-ance of re-educating the patient in respect of theirbrushing technique was also highlighted, in conjunctionto considering adjunctive cleaning aids, such as waterpicks and interdental toothbrushes.

ConclusionThe consensus viewpoint from this day was that whilstcontroversy still exists in relation to the role of ortho-dontic treatment and gingival recession, there is a needto undertake a risk assessment and appropriate consentprior to the commencement of treatment. Awarenesswas required during treatment for any signs of gingivalrecession, and the most appropriate treatment mechan-ics designed to retain the roots within the alveolar bonyenvelope was the key. There remains a relatively weakevidence base for these decisions and further prospect-ive; well designed trials are needed.

Competing interestsThe authors declare that they have no competing interests.

Authors' contributionsAJ, CK, SK, PL, MR, AS, FW and BZ were involved in leading the discussionday and were involved in writing of the manuscript. All authors have readand approved the final manuscript.

Authors' informationMR is the president of the ASE membership group.

AcknowledgementsWe are grateful to the senior, active and provisional members of the AngleSociety of Europe for their active participation in the discussions during theGingival Recession Day during the Annual Meeting in January 2013 in Going(Austria).

Received: 19 April 2013 Accepted: 2 July 2013Published: 11 July 2013

References1. Armitage GC. Development of a classification system for periodontal

diseases and conditions. Ann Periodontol. 1999; 4:16.2. Le H, Anerud A, Boysen H. The natural history of periodontal disease in

man: prevalence, severity and extent of gingival recession. J Periodontol.

1993; 64:9005.

3. Albander JM. Global risk factors and risk indicators for periodontaldiseases. Periodontol. 2002; 29:177206.

4. Genco RJ. Current view of risk factors for periodontal diseases.J Periodontol. 1996; 67:10419.

Submit your manuscript to a journal and bene t from:

7 Convenient online submission7 Rigorous peer review7 Immediate publication on acceptance7 Open access: articles freely available online7 High visibility within the eld7 Retaining the copyright to your article

Johal et al. Progress in Orthodontics 2013, 14:16 Page 5 of 5http://www.progressinorthodontics.com/content/14/1/165. Wennstrm JL, Lindhe J, Sinclair F, Thilander B. Some periodontal tissuereactions to orthodontic tooth movement in monkeys. J Clin Periodontol.1987; 14:1219.

6. Ruf S, Hansen K, Pancherz H. Does orthodontic proclination of lowerincisors in children and adolescents cause gingival recession?Am J Orthod Dentofacial Orthop. 1998; 114:1006.

7. Djeu G, Hayes C, Zawaideh S. Correlation between mandibular centralincisor proclination and gingival recession during fixed appliancetherapy. Angle Orthodontist. 2002; 72:23845.

8. Miller PD. A classification of marginal tissue recession. Int J PeriodonticsRestorative Dent. 1985; 5:813.

9. Joss-Vassalli I, Grebenstein C, Topouzelis N, Sculean A, Katsaros C.Orthodontic therapy and gingival recession: a systematic review.Orthod Craniofac Res. 2010; 13:12741.

10. Urs JC, Antonini M, Albino T, Kuijpers-Jagtman AM, Stavros K. Gingivalrecessions of lower incisors after proclination by orthodontic or surgicaldisplacement. Am J Orthod Dentofacial Orthop. 2013. in press.

11. Melson B, Allais D. Factors of importance for the development ofdehiscences during labial movement of mandibular incisors: aretrospective study of adult orthodontic patients. Am J Orthod DentofacialOrthop. 2005; 127:55261.

12. Renkema AM, Fudalej PS, Renkema A, Bronkhorst E, Katsaros C. Gingivalrecessions and the change of inclination of mandibular incisors duringorthodontic treatment. Eur J Orthod. 2012. in press.

13. Renkema AM, Fudalej PS, Renkema A, Kiekens R, Katsaros C. Developmentof labial gingival recessions in orthodontically treated patients.Am J Orthod Dentofacial Orthop. 2013; 143:20612.

14. Renkema AR, Fudalej PS, Renkema A, Abbas F, Bronkhorst E, Katsaros C.Gingival labial recessions in orthodontically treated and untreatedindividuals a pilot casecontrol study. J Clin Periodontol. 2013. in press.

15. Katsaros C, Livas C, Renkema AM. Unexpected complications of bondedmandibular lingual retainers. Am J Orthod Dentofacial Orthop. 2007;132:83841.

16. Pazera P, Fudalej P, Katsaros C. Severe complication of a bondedmandibular lingual retainer. Am J Orthod Dentofacial Orthop. 2012;142:4069.

17. Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronallyadvanced flap procedures: a systematic review. J Clin Periodontol. 2008;35(8 Suppl):13662.

18. Chambrone L, Sukekava F, Arajo MG, Pustiglioni FE, Chambrone LA, LimaLA. Root-coverage procedures for the treatment of localized recession-type defects: a Cochrane systematic review. J Periodontol. 2010;81:45278.

19. Pini-Prato GP, Cairo F, Nieri M, Franceschi D, Rotundo R, Cortellini P.Coronally advanced flap versus connective tissue graft in the treatmentof multiple gingival recessions: a split-mouth study with a 5-year follow-up. J Clin Periodontol. 2010; 37:64450.

20. Raetzke P. Covering localized areas of root exposure employing theenvelope technique. J Periodontol. 1985; 56:397402.

21. Zucchelli G, DeSanctis M. Long-term outcome following treatment ofmultiple Miller class I and II recession defects in esthetic areas of themouth. J Periodontol. 2005; 76:228692.

22. De Sanctis M, Baldini N, Goracci C, Zucchelli G. Coronally advanced flapassociated with a connective tissue graft for the treatment of multiplerecession defects in mandibular posterior teeth. Int J PeriodonticsRestorative Dent. 2011; 31:62330.

doi:10.1186/2196-1042-14-16Cite this article as: Johal et al.: State of the science on controversialtopics: orthodontic therapy and gingival recession(a report of the Angle Society of Europe 2013 meeting). Progress inOrthodontics 2013 14:16. Submit your next manuscript at 7 springeropen.com

AbstractBackgroundFindingsConclusions

FindingsIntroduction

MethodAetiology, classification, epidemiology and need for treatment of gingival recessionOrthodontic treatment and gingival recessions: what is the evidence from animal experimental studies?Orthodontic treatment and gingival recessions: what is the evidence from clinical studies?Aspects on the envelope of the lower anterior alveolar process: incisor proclination by orthodontic means or distraction osteogenesis?Gingival recession in orthodontics: a clinical matterDevelopment of gingival recessions in the post-orthodontic treatment periodIndications for increasing soft tissue thickness prior to orthodontic treatmentTreatment of gingival recession: state of the art

ConclusionCompeting interestsAuthors' contributionsAuthors' informationAcknowledgementsReferences

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