Seminars in Orthodontics 30 (2024) 95−104

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Seminars in Orthodontics
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Evidence-based rationale for the management of mucogingival deformities

before or after orthodontic treatment
Leandro Chambrone a,*, Homayoun H. Zadeh b
a
ao Interdisciplinar Egas Moniz (CiiEM), Egas Moniz School of Health & Science, Monte de Caparica, Portugal; Unit of Basic Oral
Evidence-based hub, Centro de Investigaç~
Investigation (UIBO), School of Dentistry, Universidad El Bosque, Bogota, Colombia; and Department of Periodontics, School of Dental Medicine, The University of Pennsyl-
vania, USA
b
VISTA Institute for Therapeutic Innovations, Woodland Hills, CA, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: this review aims to explore key aspects related to the treatment of gingival recession defects (GRD) and
Clinical decision-making sites lacking keratinized gingiva in orthodontic patients. It focuses on five crucial core aspects: 1) risk assessment
Phenotype for GRD development; 2) diagnosis, characteristics, and the dilemma surrounding GRD treatment necessity; 3)
Plastic surgery
the evolution of root coverage procedures and the significance of modifying soft tissue phenotype for gingival
Gingival recession
Tissue grafts
margin stability; 4) the development and progression of gingival recessions in orthodontic patients; and 5) the
staging of orthodontic and periodontal therapies; specifically, the consideration of preemptive soft tissue pheno-
type modification (STPM) or treatment of GRD.
Overview and Conclusions: the management of GRD and sites lacking gingiva or with a thin mucosal phenotype, as
well as the staging of periodontal and orthodontic treatment, should be guided by the positioning of the tooth
within the alveolar bone envelope and the periodontal phenotype. In cases where the gingival phenotype is thin
(< 1 mm), with or without GRD, it is advisable to perform preemptive soft tissue augmentation (PMT) prior to
orthodontic treatment if the tooth is located within the alveolar bone envelope. Conversely, if the tooth is posi-
tioned outside the alveolar bone housing, orthodontic tooth movement should be employed to reposition the
tooth within the bone housing before any soft tissue augmentation procedure is performed. Research has demon-
strated a negative correlation between tooth position and periodontal root coverage, whereas tooth repositioning
has shown a two-fold positive effect: 1) improving the surrounding soft tissues by reducing or eliminating the
defect, and 2) enhancing the implementation and wound healing dynamics of root coverage procedures.

Introduction cemento-enamel junction (CEJ), have been extensively studied in the field
of periodontology over the past 60 years.8−18 GRD results in partial expo-
The significance of periodontal tissue health, including the alveolar sure of the root surface, leading to esthetic, functional, and periodontal
bone, cementum, gingiva, and periodontal ligament, has long been concerns such as imbalances in "pink" and "white" esthetics, non-carious
established in periodontal literature as the primary determinant of the cervical lesions, dentin hypersensitivity, plaque accumulation, gingival
success of dental therapies.1−5 A healthy periodontium not only impacts inflammation, and root caries.8−18 The success of GRD treatment, which
the functional aspects of patients’ lives, such as proper chewing of food, involves partially or fully covering the defects, relies on three fundamen-
but also influences their overall quality of life by allowing them to tal pillars outlined by Chambrone & Avila-Ortiz in 2020: 1) identification
express their emotions.3,5 and control of causative factors leading to defect onset and progression;
Throughout an individual’s lifetime, the pristine periodontal condi- 2) assessment and analysis of defect characteristics and surrounding tis-
tions achieved soon after tooth formation and development may undergo sues; and 3) selection and execution of the most appropriate treatment
alterations in response to various factors such as aging, plaque-induced option, which may involve monitoring, non-surgical therapy, and/or sur-
periodontal diseases, and local or systemic influences.1−8 Among the vari- gical correction.
ous changes that can occur in the periodontium over time, mucogingival The impact of orthodontic treatment on the development and pro-
deformities, which involve the mucogingival complex, have garnered sig- gression of GRD has been a subject of discussion among orthodontists
nificant attention from both patients and clinicians.8−18 Gingival reces- and periodontists,19−28 primarily due to the lack of established guide-
sion defects (GRD), where the gingival margin shifts apically to the lines regarding the optimal timing and rationale for treating these

* Corresponding author at: Rua da Mooca, 2518 Cj. 13, S~ao Paulo, SP 03104-002, Brazil
E-mail address: lchamb@upenn.edu (L. Chambrone).

https://doi.org/10.1053/j.sodo.2023.09.002

1073-8746/© 2023 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/)
L. Chambrone and H.H. Zadeh Seminars in Orthodontics 30 (2024) 95−104

mucogingival deformities before or after orthodontic tooth movement.8 With respect the anatomic characteristics of the defect, different clas-
−18,28
This review aims to explore essential aspects related to the treat- sification systems can be applied to assist with the diagnosis (type of
ment of mucogingival deformities (GRD and sites lacking keratinized tis- defect), as well as therapeutic prognosis. The most widely used classifi-
sue) in orthodontic patients by focusing on four key areas: 1) cation of GRD was described by P.D. Miller in 1985 (the “Classification
understanding the etiology behind GRD development; 2) diagnosing of Marginal Tissue Recession”).42 This classification system is based into
and assessing the characteristics of GRD, and the dilemma surrounding four morphological classes:
treatment necessity; 3) examining the evolution of root coverage proce-
dures and the significance of soft tissue phenotype modification (STPM)  Class I: “Marginal tissue recession which does not extend to the
for gingival margin stability; and 4) discussing GRD development and mucogingival junction. There is no periodontal loss (bone or soft tis-
progression in orthodontic patients, with a focus on the optimal timing sue) in the interdental area, and 100 % root coverage can be
for defect treatment (before or after orthodontic treatment). anticipated”.42
 Class II: “Marginal tissue recession which extends to or beyond the
mucogingival junction. There is no periodontal loss (bone or soft tis-
Risk assessment of gingival recession defects
sue) in the interdental area, and 100 % root coverage can be
anticipated”.42
Risk factors are attributes that are associated with a given disease
 Class III: “Marginal tissue recession which extends to or beyond the
process, supported by longitudinal data. In the absence of longitudinal
mucogingival junction. Bone or soft tissue loss in the interdental
data, associated elements of risk are termed risk indicators. The deci-
area is present or there is malpositioning of the teeth which prevents
sion-making process involving the treatment of GRD is directly associ-
100 % root coverage. Partial root coverage can be anticipated”.42
ated to the identification of the risk factors/indicators associated with
 Class IV: “Marginal tissue recession which extends to or beyond the
the development of gingival recession. Risk assessment and mitigation
mucogingival junction. The bone or soft tissue loss in the interdental
of the risk factors/indicators is critical to evidence-based therapy and
area and/or malpositioning of teeth is so severe that root coverage
long-term stability of treatment. The dental literature has been identify-
cannot be anticipated”.42
ing diverse potential risk factors/indicators associated with the develop-
ment of GRD. These include those related to dental and periodontal
It is important to note that this classification system contemplates
(local) anatomy-, disease-, professional- or traumatic-related factors:
few information on soft tissue characteristics.8,43,44 Therefore, more
recently, two other GRD classifications have gained clinical attention, as
 Dental and periodontal (local) anatomical factors: tooth alignment,29
they provided changes to Miller’s system, as well as incorporated other
root prominence,19,20,30,31 thin / reduced alveolar bone,19,20 lack of
important diagnostic tools to the classification of defects:
attached gingiva32 and coronal muscle or frenum inserted near the
gingival margin33;
 The 2018 Classification of Gingival Recession Defects and Gingival
 Disease-related factors: plaque induced gingivitis and
Phenotype,43 which combines the three recession type (RT) pro-
periodontitis2,3,5,34 or viruses35;
posed by Cairo et al.45
 Iatrogenic factors: presence of defective or improper restoration (i.e.,
restorations with deficient margins or invading the periodontal
“RT1: GRD with no loss of interproximal attachment, where the
supracrestal attachment) promoting dental biofilm accumulation
Interproximal CEJ is clinically not detectable at both mesial and
and marginal inflammation36,37;
distal aspects of the tooth
 Traumatic-related factors: chemical, thermal or mechanical (i.e.,
RT2: GRD associated with loss of interproximal attachment,
traumatic toothbrushing, lip piercings) trauma promoting an inflam-
where the amount of interproximal attachment loss is less than or
matory response to the gingival tissues.38,39
equal to the buccal attachment loss
RT3: GR associated with loss of interproximal attachment, where
As clearly highlighted above, without a proper identification and
the amount of interproximal attachment loss is higher than the
mitigation of risk factors/indicators stimulating the onset and progres-
buccal attachment loss”). Additionally, these three recession
sion of recession defects, successful treatment plan cannot be established
types also account for other dental and gingival features, accord-
or maintained at long-term.10−18
ing to a diagnosis matrix formed by data related to the gingival
thickness ([thin vs. thick] assessed by tissue transparency upon
Diagnosis, characteristics and decision making for the treatment of midfacial sulcus probing), keratinized tissue width (KTW) in mm;
recession defects detectability/integrity of the CEJ (visible or not) and presence of
non-carious cervical lesions (NCCL) deeper than 1 mm.
Following GRD risk assessment, the diagnosis of such defects will
assist the clinician in rendering the best treatment options for each  The evidence-based classification system for non-proximal gingival
patient. Usually, the identification and classification of GRD is primarily recession defects designed by Chambrone & Avila−Ortiz.8 This sys-
clinical, through the assessment of recession depth, probing depth, clini- tem is formed by two important components:
cal attachment level and keratinized tissue width and thickness.8−18
However, the clinical examination, per se, cannot detect the real histo- 1) Establishment of the GRD type based on the midbuccal / midlin-
logic dimension of buccal attachment loss associated to a GRD.40 For gual attachment level respective to the interproximal bone level
instance, it has been reported that a GRD displaying 1 mm of recession
depth may be associated to an extra 2.8 mm of bone loss (i.e., bone □ GRD-I: buccal or lingual GRD in absence of adjacent interproxi-
dehiscence).40 Also, it has been shown that, for every 1 mm increase in mal attachment and bone loss
recession depth measured clinically, a successive increase of 0.98 mm in □ GRD-II: buccal or lingual GRD with adjacent interproximal
buccal bone dehiscence will be present.40 Therefore, the use of imaging attachment and bone loss (midbuccal/midlingual clinical attach-
analysis based on periapical radiographs and, mainly, CBCT data will ment level is apical to the interproximal bone level)
allow the appraisal of interproximal (i.e., height of bone crest) and buc- □ GRD-III: buccal or lingual GRD with adjacent interproximal
cal (i.e., height of bone crest bone, thickness of buccal bone plate, and attachment and bone loss (midbuccal / midlingual clinical attach-
presence of osseous dehiscence and fenestrations) bone characteristics, ment level is at the same height of or coronal to the interproximal
respectively.41 bone level;)8

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L. Chambrone and H.H. Zadeh Seminars in Orthodontics 30 (2024) 95−104

2) Assessment of the gingival phenotype according to the width of the papillae or gingival margins. This leads to improved preservation of
attached gingiva (AG) and gingival thickness (GT) the blood supply and reduction of morbidity. Moreover, the vestibular
incision provides convenient surgical access for mobilization of the gin-
□ Subtype A: Presence of ≥ 1 mm of AG and ≥ 1 mm of GT gival margins and their coronal positioning. The gingival margins are
□ Subtype B: Presence of ≥ 1 mm of AG and < 1 mm of GT fixated in coronal position with sutured that are boned to teeth with
□ Subtype C: AG is < 1 mm, independent of GT.8 flowable composite.
Overall, outcomes from the American Academy of Periodontology’s
It is important to highlight that the diagnosis and proper classifica- consensus papers9,10 and other recent systematic reviews11,13 have
tion of the defects will not only classify GRDs in a standardized way, but clearly indicated that all root coverage procedures reported in the litera-
these features can assist the clinician during the entire clinical decision- ture may promote statistically significant improvements in initial clini-
making process.8−18 For instance, the most recent classification system cal parameters. Moreover, the current base of evidence recognizes the
also provides general evidence-based treatment recommendations for use of SCTG + coronally advanced flap (CAF) as the “gold standard”
each of the types and subtypes of GRD.8 therapy for the treatment of single and multiple GRD, due the superior
Additionally, on the one hand, it can be argued that not all patients clinical outcomes (i.e., complete root coverage [CRC], mean root cover-
may wish to undergo root coverage procedures due to different reasons age [MRC] and keratinized tissue width [KTW] gain) promoted at short-
(specific details about the most used treatment approaches will be term (i.e., 6 to 12 months follow-up).8−14 In general, SCTG-based proce-
described in the following section). On the other hand, data from a sys- dures can be used to treat all types of GRD, but the specific clinical indi-
tematic review on the clinical behavior of untreated GRD, followed up cations will rely on the number of defects to be treated, the flap
for at least a 2-year period, demonstrated that the majority of untreated characteristics (i.e., quality /thickness and width of the gingival tissue
GRD (78.1 %), in individuals with good oral hygiene, displayed reces- included the flap, amount of SCTG to be harvested from the donor sites
sion depth increase and clinical attachment loss.46 (i.e., palate or tuberosity), medical contraindications for autogenous soft
tissue harvesting, or patient preferences.8−14 Among those clinical sce-
Soft tissue augmentation highlights: the evolution of root coverage narios where the uses of SCTG is precluded, CAF-based procedure (con-
procedures and the importance of soft tissue phenotype ventional or tunneling techniques) plus allogenic or xenogenic soft
modification for gingival margin stability tissue substitutes, biologics (i.e. enamel matrix derivatives, platelet-rich
fibrin and recombinant human platelet-derived growth factor BB), CAF
The concept of soft tissue augmentation involves the use of flaps (i.e., (or a laterally positioned flap) alone, or even a free gingival graft may be
rotated, laterally or coronally positioned) or grafts / substitutes (i.e., used.8−14 In this regard, the choice of procedures from “best to worst”,
autogenous, allogenic or xenogenic) to promote improvements of the the use of CAF-based procedures plus allogenous dermal matrix (primar-
gingival tissues (i.e., gains in the width and thickness of keratinized tis- ily), followed by xenogeneic collagen matrix (secondarily) and platelet-
sue) surrounding a tooth.8−18 From a historical perspective, the origins rich fibrin (tertiarily) have been ranked as the most suitable alternatives
of root coverage procedure go back to the early 20th century, where the to SCTG, when both root coverage and gingival / STPM are the treat-
use of pedicle and free gingival grafts (harvested from the tuberosity ment goals.8−11,13,14
area) were proposed for the treatment of GRD.47 Later on, between the For sites not requiring root coverage (that is teeth where only
middle 1950′s and the early 2000′s several monolaminar (i.e., flaps or improvements in the width and thickness of gingiva / keratinized tissue
free gingival grafts alone) and bilaminar (i.e., subepithelial connective band is required), free gingival grafts will promote the best clinical out-
tissue grafts [SCTG] or soft tissue substitutes / materials completely or comes, followed by the combination of SCTG + flap (preferably a
partially covered by a mucosal flap) root coverage procedures have been tunneling approach).52 However, the use of free gingival grafts is best
developed to treat single and multiple GRD, periodontal soft tissue phe- indicated for the treatment of non-esthetic sites (i.e., mandibular teeth),
notype modification (STPM) with the primary aims of reducing / elimi- as the epithelial layer contained in the graft promotes texture and color
nating recession depth, increasing the clinical attachment level, changes to the recipient sites (i.e., a more fibrotic texture and a lighter
increasing mucosal thickness and improving the keratinized tissue gingival color), compared to other grafts.8−18,52 Thus, the use of SCTG
band.8−18 (or a soft tissue substitute) is more suitable for esthetic areas (i.e., maxil-
In recent years, the 21st century studies have focused on maximizing lary teeth).8−18,52
clinical and patient-reported outcomes (i.e., the achievement of com- As reported above, one of the goals of soft tissue augmentation, in
plete root coverage, a perfect integration of the graft with the recipient sites with or without GRD, regards the achievement of STPM. STPM it is
site / adjacent soft tissues, reduction of patient morbidity and improved a concept that regards to both histologic and clinical alterations to the
esthetics) through a better understanding of flap refinement and man- pre-established, original genetic characteristics of the recipient site pro-
agement (i.e. promoted by improvements on flap design, preparation, moted by soft tissue grafts (i.e., autogenous, as well as allogenous and
positioning and suture).8−14 Other advances promoted, over the last two xenogenic substitutes).9,15 From a histologic perspective, STPM pro-
decades, by the development of new macro and micro surgical instru- motes a thickening of the epithelial layer, as well as an increase in the
ments, suturing materials and the use of magnification appliances (i.e., number and density of collagen bundles contained in the lamina prop-
loupes and surgical microscopes) reduced the naturally occurring ria.53 From a clinical perspective, STPM is mainly associated to improve-
trauma caused to the treated sites (i.e., these where designed to promote ments in the width and thickness of the keratinized tissue band (i.e.,
a less traumatic flap dissection and stabilization) and fostered the wound gingiva).8−18,52
healing process.8−14 Additionally, new histological and clinical studies The importance of changing a thin to a thick mucosal phenotype has
focusing on the potential applications of subepithelial connective tissue been demonstrated by both short- and long-term studies.8−18,52−54 For
grafts harvested from different intra-oral donor sites,48 the performance instance, it has been reported that the thicker the recipient site after 6
of different harvesting procedures,49−51 the development of novel soft months wound healing, the greater the possibility of achieving CRC.54,55
tissue substitutes,8−13 and the impact of periodontal STPM in the long- Usually, sites submitted to STPM displayed more CRC and MRC.9−14,52
term stability of results achieved with therapy9,10,12−18 have been form- Moreover, the outcomes from long-term studies (> 5 years) have demon-
ing the basis of current clinicians and researchers interest during recent strated that a minimum of 1 mm thickness and 2 mm width of attached
years. gingiva is necessary to maintain the stability of the gingival margin over
One such innovation has been the vestibular incision subperiosteal time, for both treated15−18 and untreated sites,46 in patients with good
tunnel access (VISTA) technique. This entails making a vestibular inci- standards of oral hygiene. These positive results are demonstrated as
sion that is remote from the gingival recessions without any incisions at follows:

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L. Chambrone and H.H. Zadeh Seminars in Orthodontics 30 (2024) 95−104

 Outcomes from medium- to long-term studies identified that teeth analysis may be used to improve the decision-making process and help
lacking a minimum 2 mm of gingiva were more susceptible to clini- to prevent the development of GRD. In particular in patients with thin
cal attachment loss (i.e., GRD onset and progression)46; periodontal phenotype, who are at increased risk for developing addi-
 Teeth presenting with a thin gingival phenotype treated with STPM tional periodontal tissue loss, 3D imaging may be most useful.41 More-
via free gingival grafts, displayed less onset and progression of over, the accurate appraisal of buccal bone height and thickness (and
GRD18 and non-carious cervical lesions,15 25 or more years after gin- the detection of bone fenestrations) before treatment, promoted by
gival augmentation therapy. Additionally, it has been shown that: a) CBCT imaging, will be particularly important in the anterior mandible
83.5% of treated sites displayed 1 to 4 mm of coronal displacement and maxillary premolar regions.41
of the gingival margin (a phenomenon also known as “creeping As previously highlighted in this article, GRD do not spontaneously
attachment”) after a 25-year follow-up period)18 ;and b) teeth exhib- improve,46 and their development and progression can be an adverse
iting a thin or reduced (< 2 mm) attached gingiva were associated to effect of inappropriate or excessive orthodontic tooth movement in a
a 3.5 times bigger chance of developing non-carious lesions, com- buccal direction, leading to breakdown of the alveolar process, including
pared to sites displaying a thick gingival phenotype or ≥ 2 mm of connective tissue and marginal bone loss,19−28,56 In such a way, proper
attached gingiva, 25 to 30 years after surgery15; identification of mucogingival deformities will allow the proposal of per-
 The use of a monolaminar procedure (i.e., a CAF-based procedure sonalized treatment approaches and the maintenance of a clinically
alone) will be efficient in maintaining the stability of the gingival at healthy and stable periodontium.63 Therefore, the decision-making pro-
long-term, only at sites, where a thick soft tissue was present prior cess for orthodontic therapy should be based on the periodontal charac-
treatment. Data from a 20-year follow-up study showed that, in GRD teristics of the treated sites (Fig. 1), in order to assist the orthodontist in
sites without a minimum 2 mm of attached gingiva width prior sur- identifying the need of forwarding a patient to soft tissue augmentation
gery, the use of CAF alone was not able to change the original charac- therapy, prior or after promoting orthodontic tooth movement. From a
teristics of the keratinized tissue band, nor to prevent GRD periodontal perspective, six factors should be accounted when designing
recurrence17; a orthodontic treatment plan: 1) an initial interdisciplinary evaluation
 GRD treated by bilaminar approaches, such as SCTG + CAF, will not performed by the periodontist and the orthodontist, especially among
only lead to satisfactory short-term root coverage outcomes, but patients presenting mucogingival deformities; 2) presence or achieve-
these sites will present better gingival margin stability, compared to ment of periodontal health before beginning orthodontic treatment; 3)
CAF-treated sites,17 20 years after treatment, as well. Overall, the knowledge on wound healing outcomes of soft tissue augmentation pro-
presence of ≥ 2 mm of attached gingiva precluded the relapse of cedures − orthodontic tooth movement shall be applied 3 to 6 months
GRD.16 after surgery; 4) appraisal of the effects of buccal orthodontic move-
ment, duration and forces on the stability of gingival margin and bone
The issue of gingival recessions development and progression in crest; 5) promotion of regular periodontal maintenance care during the
orthodontic patients and staging of treatment orthodontic treatment; and 6) joint periodontal and orthodontic evalua-
tion of the final outcomes − this should be based on the outcomes
It has been reported that the development and progression of GRD in accomplished by periodontal therapy (i.e., the maintenance of the
orthodontic patients is associated to a binomial formed by local anatomy patient periodontal clinical attachment levels’) and the achievement of
of the periodontium and the characteristics of buccal orthodontic tooth proper tooth alignment and occlusion.63
movement.19−28,56 Moreover, it has been demonstrated that individuals Despite the massive data on soft tissue augmentation procedures
who experienced the development of single gingival recessions during published over the last decades, few information from human clinical
orthodontic treatment are more prone to present sites of multiple GRD studies have addressed staging of periodontal and orthodontic treat-
after therapy.57 ment.64 On the one hand, evidence from preclinical studies, case reports
The rationale for determining the need for treating mucogingival and case series support that buccally positioned teeth presenting muco-
deficiencies (e.g., sites with GRD, inadequate keratinized or thin gin- gingival deformities, with roots located outside the bone housing,
giva) in orthodontic patients and sequencing of treatment, requires should undergo orthodontic tooth movement (torqueing and / or trans-
understanding of periodontal anatomy and behavior of sites treated lation movement), to reposition the tooth inside bone housing (back
with STPM. As a common sense, changes to the gingiva and attachment within the alveolar bone process) before performing any soft tissue aug-
structures, promoted by orthodontic therapy, will be directly related to mentation procedure.65−68 It has been demonstrated that both the
the future torque and positioning of each individual tooth in relation to GRD65−70 depth and bone dehiscence66,69,70 may be reduced when tooth
the alveolar ridge.19,20,21,26,28,57 The presence of a thin periodontal phe- is moved into the bone envelope. On the other hand, STPM performed
notype (i.e., thin gingiva and alveolar bone) may contribute to the devel- prior orthodontic therapy appears as “a clinically-driven approach indi-
opment of orthodontic-related GRD.22 As demonstrated by the dental cated in reducing the risk of additional attachment loss caused by poten-
literature, the buccal bone has two important “unfavorable” anatomic tially deleterious tooth movements, outside the buccal alveolar bone
characteristics: 1) it has a reduced thickness compared to the lingual envelope,” in patients presenting mucogingival deformities, in which
wall; and 2) it may contain fenestrations and dehiscence.58−62 Regard- the buccal lingual width of the bone is superior than buccal—lingual
ing these bone features, the presence of fenestrations and dehiscence tooth dimension.28,58,71−74 It should be noted that in cases where the
have been detected in most individuals (i.e., 60 %) and in up to 50 % of buccal-lingual width of the bone is equal or inferior than that of the
mandibular anterior teeth.59 Taking into consideration only patients dis- tooth, lingual tooth movements could create a new GRD on the lingual
playing Class I, II or III malocclusion the proportion of teeth presenting side of the tooth. Consequently, the decision-making process of such
fenestrations and dehiscence may also be considered high, as demon- cases should primarily involve the surgical treatment of the mucogingi-
strated by a couple of studies61,62: a) it varied from 36.5 % (fenestra- val deformity, although partial lingual tooth movement might be consid-
tions) to 51.1 % (dehiscence) among Class I and Class II Division on ered prior surgery, based on the characteristics of the lingual bone wall
maloclusion61; b) the prevalence of mandibular bone defects among (Fig. 1). Furthermore, histological preclinical data supports the assump-
Class II and Class III malocclusion patients varied between 41.1 % and tion that STPM (via free gingival graft) can prevent GRD development
45.0 %, respectively62 ;and c) mandibular incisors displayed the highest and preclude buccal soft tissue thinning after a buccal orthodontic tooth
number of dehiscence, independently of the type of malocclusion.62 movement.75 Furthermore, outcomes from a recent randomized clinical
Recent American Academy of Periodontology’s Best Evidence sys- trial comparing root coverage prior orthodontic treatment (via
tematic review on the use of CBTC for risk assessment of the dentoalveo- SCTG + CAF) versus orthodontic treatment only,76 identified two inter-
lar bone changes influenced by tooth movement, 3-dimensional imaging esting issues: 1) lack of GRD relapse (i.e., stability of root coverage

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L. Chambrone and H.H. Zadeh Seminars in Orthodontics 30 (2024) 95−104

Fig. 1. Mucogingival Periodontal-Orthodontic Treatment Algorithm

(AG: attached gingiva; CAF: coronally advanced flap; CATF: coronally advanced tunnel flap; GRD: gingival recession defect; GT: gingival thickness; GTR: guided tis-
sue regeneration; LPF: laterally positioned flap; OHM: oral hygiene measures; OFD: open flap debridement; PMT: phenotype modification therapy; SC/RP: scaling and
root planning; SCTG: subepithelial connective tissue graft; SS: supragingival scaling). * The decision-making process of such cases should primarily involve the surgical
treatment of the mucogingival deformity, although partial lingual tooth movement might be considered prior surgery, based on the characteristics of the lingual bone
wall.

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L. Chambrone and H.H. Zadeh Seminars in Orthodontics 30 (2024) 95−104

Fig. 2. Clinical case of a patient with anterior crowding and gingival recession defects, who was planning on orthodontic therapy (A, B, C, D). The 3D imaging data
revealed very narrow alveolar bone with facial dehiscence present on some of the mandibular teeth (E, F, G, H). Soft tissue phenotype modification was carried out
using VISTA technique which entailed vestibular vertical incisions (I). Subperiosteal tunnel (full thickness dissection) was made, followed by coronal advancement of
the gingival tissues to cover the recession defects. To maintain the tissues coronally, sutures were bonded to teeth with flowable composite. The graft consisted of acel-
lular dermal matrix infused with recombinant platelet derived growth factor (J). Two strips of 1 × 4 cm acellular dermal matrix were placed into the right (K) and left
(L) vestibular tunnels. The dermal grafts were stabilized in coronal position within the vestibular tunnel (M). Platelet rich fibrin matrices were placed inside the vestib-
ular tunnel to aid with the post-operative healing (N) and the initial incisions were approximated with sutures (O). Post-operative healing after one week illustrates a
favorable healing (P). The sutures were removed after 3 weeks. Pre-orthodontic position of the mandibular teeth (Q, R). Orthodontic digital planning was conducted
very carefully to avoid disturbing the root positions within the alveolar bone, showing super-imposition of pre- and post-operative positions (S). Orthodontic simulated
position of the mandibular teeth (T). Final clinical images showing post-orthodontic position of the teeth, periodontal root coverage after successful periodontal plastic
surgery with increased soft tissue phenotype (U, V, W, X).

outcomes) after the competition of orthodontic treatment76; and 2) condition / outcome that will act as a physical-mechanical barrier
improvements in the keratinized tissue width / gingival phenotype and against local / environmental factors and lateral and occlusal, and thus,
cervical hypersensitivity reduction.76 prevent gingival recession relapse.28
Another recent CBCT analysis showed evidence of “new bone regen-
eration in the direction of orthodontic movement” after STPM, when Case 1
SCTG + CAF was performed in patients with an attached
gingiva < 1 mm and a thin periodontal phenotype (i..e, thin scalloped The clinical case shown in Fig. 2 is an example of a 44 years old
gingiva and alveolar bone thickness < 1 mm).77 The authors of this case patient with mandibular anterior crowding, who was planning to
series also advocated that the keratinized tissue gains and the formed undergo orthodontic therapy to treatment. Periodontal examination
new bone could prevent the onset of GRD during proclination or buccal (Fig. 2A, B) revealed the presence of 2−3 mm of localized recession
tooth movement.77 defects in the right posterior mandible and 1−3 mm of gingival reces-
In reality, most orthodontic movements are complex, involving trans- sion in the mandibular anterior region. Some of the recessions were
lation and inclination, where during some stages, movements are in the Cairo class 1 (RT1), meaning without loss of interdental tissue. Others
direction of the alveolar bone and at other stages movements are in had some interdental tissue loss, being classified as Cairo class 2 (RT2).
opposite direction. Therefore, the safest approach is to consider STPM The mandibular teeth possessed only minimal band of keratinized gin-
prior to orthodontic movement. While this approach will minimize giva (approximately 2 mm) with thin gingival phenotype. Gingival
potential recession during orthodontic treatment, the position of the thickness was assessed based on the visibility of a periodontal probe
roots may compromise periodontal root coverage. If this approach is fol- through the gingival margin, where thin phenotype sites (<1.0 mm) can
lowed, it may be necessary to perform an additional coronal positioning be identified via probe visibility, whereas thick phenotype sites do
of the gingival margin after orthodontic treatment. not.78 The periodontal phenotype with thin minimal keratinized gingiva
In addition, the issue of treating GRD developed after orthodontic is considered important risk indicators that increase the likelihood of
therapy was not addressed in this review, but there is clear indication gingival recession development during orthodontic tooth movement.
that the results of STPM will be effective at short-term, as well may be Alveolar bone thickness was also very narrow, showing several areas of
maintained over time.28,73 As highlighted by a recent compressive facial dehiscence (Fig. 2E−H). In view of the thin periodontal pheno-
review on this topic, STPM can reduce or completely eliminate GRD and type, the decision was made to perform soft tissue phenotype modifica-
increase the keratinized tissue / gingiva width and thickness, a tion therapy prior to orthodontic therapy. Since approximately 2 mm of

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L. Chambrone and H.H. Zadeh Seminars in Orthodontics 30 (2024) 95−104

Fig. 3. Clinical case of a patient who was planning on orthodontic therapy to address deep bite, supra-eruption of mandibular anterior teeth and constricted arches (A,
B). Since some teeth were located outside of alveolar bone and anterior gingival recession defects, the treatment sequence involved an initial phase of clear aligner ther-
apy to improve the position of the roots within alveolar bone (C,D). A short course of Clear Aligner Therapy was implemented resulting in improved root position (E, F).
Soft tissue phenotype modification was carried out using VISTA technique which entailed vestibular vertical incisions (G). Subperiosteal tunnel (full thickness dissec-
tion) was made (H). Collagen matrix (20 × 40 × 6 mm) was cut longitudinally, infused with liquid platelet rich fibrinogen and each of the pieces were inserted into the
right (I) and left (J) subperiosteal tunnels. Mattress sutures were placed into the gingival margins and were coronally positioned and anchored in that position by bond-
ing with flowable composite (K). Several solid matrix platelet rich fibrin were inserted into the subperiosteal tunnel (L). The sutures were left in for 3 weeks (M) after
which the sutures and composite bondings were removed. After 5 weeks (N, O) and four months (P), complete root coverage and significant gingival thickness gain
was achieved. Additional course of clear aligner therapy was undertaken to further address the initial orthodontic objectives. The pre-orthodontic simulation (Q) and
clinical image (R). Clear aligner therapy utilized buttons and class II elastics (S) to approximate the simulated outcome (T). Two-year follow-up shows stability of soft
tissues following completion of orthodontic therapy (U, V, W, X).

keratinized gingiva was present, it was considered unnecessary to har- healing. Initial wound healing was uneventful as demonstrated by clini-
vest autogenous tissue from patient. Acellular dermal matrix (ADM) was cal image after one week post-surgically. Once the healing following
infused with recombinant human platelet derived growth factor periodontal plastic surgery was stabilized, clear aligner orthodontic ther-
rhPDGF) and used as graft material. Vestibular incision subperiosteal apy was commenced and took approximately 6 months. In view of the
tunnel access (VISTA) was used to as a minimally invasive periodontal narrow alveolar bone, the orthodontic movements were planned in such
plastic surgery technique. This technique entailed vestibular vertical way to minimize facial translation or proclination of the mandibular
incisions made anterior of mandibular canines. From the initial inci- anterior teeth (Fig. 2M and P). Post-operative outcome showed ortho-
sions, subperiosteal tunneling was elevated in a manner analogous to dontic correction of the crowding. Periodontal outcome was character-
full thickness flap elevation, except in VISTA no marginal incisions are ized by thick soft tissue phenotype without any evidence of clinical
made. The subperiosteal tunneling allowed for mobilization of the recession.
mucoperiosteal complex. The gingival margins were coronally posi-
tioned not only to cover exposed root surfaces but also to over-correct Case 2
and move the gingival margins at least 2−3 mm coronal to the cemen-
toenamel junction. To ensure wound stability during the healing pro- The second case (Fig. 3) presents a 59 years old patient with sev-
cess, gingival margins were fixated to teeth in coronal position with aid eral orthodontic issues, including deep bite, supra-eruption of man-
of sutures that were bonded to teeth with composite resin. The rhPDGF- dibular anterior teeth, and constricted arches (Fig. 2A, 3B). Gingival
infused ADM was introduced within the vestibular tunnel, followed by recession defects, classified as Cairo class RT1, were identified during
introduction of multiple platelet rich fibrin matrices to enhance wound the periodontal examination. The patient had a thin gingival

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L. Chambrone and H.H. Zadeh Seminars in Orthodontics 30 (2024) 95−104

Fig. 4. Patient presented with chief complaint of gingival

recession, including interproximal black triangles. Pre-
orthodontic simulation of intra-oral scan (A) and clear
aligner orthodontic simulation (B). Simulation of initial
stage of the second phase (C) and third phase (E) of clear
aligner therapy, showing semi-transparent bone and roots.
Simulation of final stage of the second phase (D) and third
phase (F). Smile (G) and clinical image of maxilla (H) at
initial presentation. Final smile (I) and clinical image (J) of
the maxilla.

phenotype78 but sufficient keratinized gingiva (> 2 mm). The thin margins and coronally positioned and anchored in place by bonding
gingival tissue could have predisposed him to exacerbation of the gin- with flowable composite (Fig. 3K). Additionally, six platelet-rich
gival recession. However, the prominent root positions would have fibrin solid matrices were inserted into the apical regions of the sub-
posed challenges to periodontal plastic surgery, potentially leading to periosteal tunnel (Fig. 3L). The sutures were kept in place for three
compromised results. To address these concerns, the treatment weeks to ensure wound stability (Fig. 3M). Following the 3-week
sequence involved an initial phase of clear aligner therapy to improve healing period, the sutures and composite bondings were removed.
the position of the roots within the alveolar bone (Fig. 3C, 3D). In this After five weeks (Fig. 3N, O) and four months (Fig. 3P), complete root
phase, the primary focus was on improving root position (Fig. 3E, F). coverage and significant gingival thickness gain were achieved. Fol-
The soft tissue phenotype modification was performed using the lowing removal of the bondings, thermoplastic retainers were pro-
VISTA technique, starting with vestibular vertical incisions (Fig. 3G). vided to the patient to avoid orthodontic relapse during the healing
A subperiosteal tunnel was created with specialized tunneling instru- period. The retainers were made with distance to the gingival margins
ments (Fig. 3H). For soft tissue phenotype modification, a volume-sta- of the teeth to avoid gingival adverse effects. An additional course of
ble collagen matrix (FibroGide 20 × 40 × 6 mm, Geistlich, Wulhosen, clear aligner therapy was undertaken to address the initial orthodon-
Switzerland) was longitudinally cut into two pieces. The collagen tic objectives. The pre-orthodontic simulation (Fig. 3Q) and clinical
matrix was infused with liquid platelet-rich fibrinogen (Intraspin, image (Fig. 3R) showed clear aligner therapy utilizing buttons and
BioHorizons, Birmingham, AL). The two PRF-loaded collagen matrix class II elastics (Fig. 3S) to approximate the simulated outcome
pieces were then inserted into the right (Fig. 3I) and left (Fig. 3J) sub- (Fig. 3T). The two-year follow-up demonstrated the stability of soft
periosteal tunnels. Mattress sutures were placed into the gingival tissues following the completion of orthodontic therapy (Fig. 3U−X).

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L. Chambrone and H.H. Zadeh Seminars in Orthodontics 30 (2024) 95−104

Case 3 movement. Even in the presence of a favorable periodontium with thick

gingiva and bone, GRD may still occur or worsen during orthodontic
The third clinical case involved a 66-year-old female, who presented treatment when the anatomical characteristics of periodontal tissues are
with gingival recession defects, including interproximal tissue loss, com- not adequately considered.
monly referred to as black triangles (Fig. 4). These may be classified as
Cairo RT2 (Miller Class III). After a risk assessment, the patient was Patient consent
informed that periodontal plastic surgery might not be a reliable option
for correcting the interproximal recession. Instead, clear aligner ortho- Patient consent was obtained.
dontic therapy was chosen with the goal of optimizing root positions.
The orthodontic plan comprised three phases, with interproximal reduc- Funding
tion conducted at each phase, totaling 1.4 mm between the maxillary
central incisors. During the second phase of orthodontic treatment, addi- No funding or grant support.
tional tools became available in the planning software, allowing for
intraoral surface scans to be superimposed on CBCT 3D imaging data. Author contributions
This enabled visualization of the roots through alveolar bone simulation,
which could be made semi-transparent. It is important to note that in All authors attest that they meet the current ICMJE criteria for
this simulation, the alveolar bone is assumed to remain static, and authorship.
changes to the bone are not simulated.
Declaration of competing interest
Concluding remarks
The authors declare that they have no known competing financial
The treatment of mucogingival deformities in orthodontic patients
interests or personal relationships that could have appeared to influence
necessitates a comprehensive understanding of the role of underlying
the work reported in this paper.
risk factors on periodontal tissues. The rationale for managing gingival
recession defects (GRD) and sites lacking attached gingiva (i.e., an
Acknowledgments
attached keratinized tissue width), either before or after orthodontic
treatment, should be supported by three fundamental pillars, which
The authors do not have any financial interest in the companies
involve the use of root coverage procedures and soft tissue phenotype
whose materials are included in this article.
modification (STPM): 1) Thorough risk assessment and management/
mitigation: A comprehensive evaluation of the risk factors associated
with GRD development and the implementation of appropriate measures References
to mitigate those risks. 2) Clinical and imaging evaluation: A compre-
1. American Academy of Periodontology. Consensus report: chronic periodontitis. Ann
hensive assessment of the characteristics of the deformity (e.g., extent Periodontol. 1999;4:38.
and severity of the defect) and the adjacent periodontal tissues (e.g., 2. Heitz-Mayfield LJA, Sch€atzle M, L€ oe H, et al. Clinical course of chronic periodontitis.
attached gingiva, gingival and bone thickness). In cases where neces- II. Incidence, characteristics and time of occurrence of initial periodontal lesion. J Clin
Periodontol. 2003;30:902–908.
sary, the use of advanced imaging techniques such as cone-beam com- 3. Trindade D, Carvalho R, Machado V, et al. Prevalence of periodontitis in dentate peo-
puted tomography (CBCT) may be considered. 3) Execution of the most ple between 2011 and 2020: a systematic review and meta-analysis of epidemiological
suitable soft tissue augmentation procedure: Based on the evaluation studies. J Clin Periodontol. 2023;50:604–626.
4. Botelho J, Machado V, Leira Y, et al. Economic burden of periodontitis in the United
mentioned above, the selection and implementation of the most appro- States and Europe: an updated estimation. J Periodontol. 2022;93:373–379.
priate technique for soft tissue augmentation to achieve desired out- 5. Carvalho R, Botelho J, Machado V, et al. Predictors of tooth loss during long-term peri-
comes. odontal maintenance: an updated systematic review. J Clin Periodontol. 2021;48:1019–
1036.
Proper staging of orthodontic and periodontal therapy: Considering 6. Glickman I, Smulow JB. Buttressing bone formation in the periodontium. J Periodontol.
the positioning of the tooth within the bone envelope and the surround- 1965;36:365–370.
ing periodontal phenotype, a well-planned sequence of orthodontic and 7. Chambrone LA, Chambrone L. Bony exostoses developed subsequent to free gingival
grafts: case series. Br Dent J. 2005;199:146–149.
periodontal interventions should be established.
8. Chambrone L, Avila-Ortiz G. An evidence-based system for the classification and clini-
When identifying teeth with GRD or teeth lacking attached gingiva cal management of non-proximal gingival recession defects. J Periodontol.
and gingival thickness (< 1 mm), indicating a thin periodontal pheno- 2021;92:327–335.
type, the consideration of soft tissue augmentation therapy becomes 9. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: a system-
atic review from the AAP Regeneration Workshop. J Periodontol. 2015;86(2 Suppl):
essential. This may involve periodontal phenotype modification therapy S8–51.
with or without root coverage before initiating orthodontic treatment, 10. Chambrone L, Barootchi S, Avila-Ortiz G. Efficacy of biologics in root coverage and gingi-
particularly if the tooth is located within the bone envelope. Evidence val augmentation therapy: an American academy of periodontology best evidence system-
atic review and network meta-analysis. J Periodontol. 2022;93:1771–1802.
suggests that a thick mucosal phenotype acts as a physical barrier, pre- 11. Chambrone L, Botelho J, Machado V, et al. Does the subepithelial connective tissue
venting the apical displacement of the gingival margin (i.e., the develop- graft in conjunction with a coronally advanced flap remain as the gold standard ther-
ment and progression of GRD). apy for the treatment of single gingival recession defects? A systematic review and net-
work meta-analysis. J Periodontol. 2022;93:1336–1352.
In cases where the tooth with mucogingival deformity is positioned 12. Chambrone L, Pini Prato GP. Clinical insights about the evolution of root coverage
outside the alveolar bone envelope, orthodontic tooth movement, incor- procedures: the flap, the graft, and the surgery. J Periodontol. 2019;90:9–15.
porating torque and/or translation movement, should be implemented 13. Chambrone L, Ortega MAS, Sukekava, et al., et al. Root coverage procedures for treat-
ing single and multiple recession-type defects: an updated Cochrane systematic
to reposition the tooth within the bone housing (back within the alveo- review. J Periodontol. 2019;90:1399–1422.
lar bone process) before performing any soft tissue augmentation proce- 14. Chambrone L, de Castro Pinto RCN, Chambrone LA. The concepts of evidence-based
dure. Studies have shown a negative correlation between root periodontal plastic surgery: application of the principles of evidence-based dentistry
for the treatment of recession-type defects. Periodontol 2000. 2019;79:81–106.
prominence and root coverage.30,31 Tooth repositioning offers a dual
15. Agudio G, Chambrone L, Selvaggi F, et al. Effect of gingival augmentation procedure
benefit: 1) improving the soft tissues surrounding the deformity by (free gingival graft) on reducing the risk of non-carious cervical lesions: a 25- to 30-
reducing or eliminating the defect, and 2) enhancing the implementa- year follow-up study. J Periodontol. 2019;90:1235–1243.
tion and wound healing dynamics of root coverage procedures. 16. Pini Prato GP, Franceschi D, Cortellini P, et al. Long-term evaluation (20 years) of the
outcomes of subepithelial connective tissue graft plus coronally advanced flap in the
Regular periodontal monitoring and care are essential to identify treatment of maxillary single recession-type defects. J Periodontol. 2018;89:1290–
potential gingival changes that may occur during orthodontic tooth 1299.

103
L. Chambrone and H.H. Zadeh Seminars in Orthodontics 30 (2024) 95−104

17. Pini Prato GP, Magnani C, Chambrone L. Long-term evaluation (20 years) of the out- 50. Kahn S, Ara ujo ITE, Dias AT, et al. Histologic and histomorphometric analysis of con-
comes of coronally advanced flap in the treatment of single recession-type defects. J nective tissue grafts harvested by the parallel incision method: a pilot randomized con-
Periodontol. 2018;89:265–274. trolled trial comparing macro- and microsurgical approaches. Quintessence Int.
18. Agudio G, Chambrone L, Pini Prato G. Biologic remodeling of periodontal dimensions 2021;52:772–778.
of areas treated with gingival augmentation procedure: a 25-year follow-up observa- 51. Schinini G, Sales D, G omez MV, et al. Healing of donor sites of connective tissue grafts
tion. J Periodontol. 2017;88:634–642. harvested by the single incision technique: a randomized clinical trial evaluating the use
19. Steiner GG, Pearson JK, Ainamo J. Changes of the marginal periodontium as a result of of collagen hemostatic sponge with or without sutures. J Periodontol. 2021;92:629–636.
labial tooth movement in monkeys. J Periodontol. 1981;52:314–320. 52. Barootchi S, Tavelli L, Zucchelli G, et al. Gingival phenotype modification therapies on
20. Wennstr€ om JL, Lindhe J, Sinclair F, et al. Some periodontal tissue reactions to ortho- natural teeth: a network meta-analysis. J Periodontol. 2020;91:1386–1399.
dontic tooth movement in monkeys. J Clin Periodontol. 1987;14:121–129. 53. James WC, McFall Jr WT, Burkes EJ. Placement of free gingival grafts on denuded
21. Wennstr€ om JL. Mucogingival considerations in orthodontic treatment. Semin Orthod. alveolar bone. part II: microscopic observations. J Periodontol. 1978;49:291–300.
1996;2:46–54. 54. Ahmedbeyli C, Ipçi SD, Cakar G, et al. Clinical evaluation of coronally advanced flap
22. Melsen B, Allais D. Factors of importance for the development of dehiscences during with or without acellular dermal matrix graft on complete defect coverage for the
labial movement of mandibular incisors: a retrospective study of adult orthodontic treatment of multiple gingival recessions with thin tissue biotype. J Clin Periodontol.
patients. Am J Orthod Dentofacial Orthop. 2005;127:552–561. 2014;41:303–310.
23. Aziz T, Flores-Mir C. A systematic review of the association between appliance- 55. Ahmedbeyli C, Dirikan Ipçi S, Cakar G, et al. Coronally advanced flap and envelope type
induced labial movement of mandibular incisors and gingival recession. Aust Orthod J. of flap plus acellular dermal matrix graft for the treatment of thin phenotype multiple
2011;27:33–39. recession defects. A randomized clinical trial. J Clin Periodontol. 2019;46:1024–1029.
24. Joss-Vassalli I, Grebenstein C, Topouzelis N, et al. Orthodontic therapy and gingival 56. Vanarsdall RL. Orthodontics and periodontal therapy. Periodontol. 1995;9:132–149.
recession: a systematic review. Orthod Craniofac Res. 2010;13:127–141. 2000.

25. Rasperini G, Acunzo R, Cannalire P, et al. Influence of periodontal biotype on root sur- 57. Artun J, Grobety D. Periodontal status of mandibular incisors after pronounced ortho-
face exposure during orthodontic treatment: a preliminary study. Int J Periodontics dontic advancement during adolescence: a follow-up evaluation. Am J Orthod Dentofac
Restorative Dent. 2015;35:665–675. Orthop. 2001;119:2–10.
26. Jepsen K, Sculean A, Jepsen S. Complications and treatment errors involving peri- 58. Chambrone L. Evidence-based Periodontal and Peri-implant Plastic Surgery: A Clinical
odontal tissues related to orthodontic therapy. Periodontol 2000. 2023;92:135–158. Roadmap from Function to Aesthetics. Cham:Springer International Publishing; 2015.
27. Ashfaq M, Sadiq A, Sukhia RH, et al. Association of hard and soft tissue factors with 59. Rupprecht RD, Horning GM, Nicoll BK, et al. Prevalence of dehiscences and fenestra-
gingival recession in orthodontically treated patients: a retrospective study. Int Orthod. tions in modern American skulls. J Periodontol. 2001;72:722–729.
2021;19:60–66. 60. Nowzari H, Molayem S, Chiu CH, et al. Cone beam computed tomographic measure-
28. Chambrone L, Garcia-Valenzuela FS. Periodontal phenotype modification of com- ment of maxillary central incisors to determine prevalence of facial alveolar bone
plexes periodontal-orthodontic case scenarios: a clinical review on the applications of width ≥2 mm. Clin Implant Dent Relat Res. 2012;14:595–602.
allogenous dermal matrix as an alternative to subepithelial connective tissue graft. J 61. Evangelista K, Vasconcelos KF, Bumann A, et al. Dehiscence and fenestration in
Esthet Restor Dent. 2023;35:158–167. patients with Class I and Class II Division 1 malocclusion assessed with cone-beam
29. Stoner J, Mazdyasna S. Gingival recession in the lower incisor region of 15-year-old computed tomography. Am J Orthod Dentofacial Orthop. 2010;138:133.e1–133.e7.
subjects. J Periodontol. 1980;51:74–76. 62. Yagci A, Veli I, Uysal T, et al. Dehiscence and fenestration in skeletal Class I, II, and III
30. Gil A, Bakhshalian N, Min S, Nart J, Zadeh HH. Three-Dimensional Volumetric Analysis of malocclusions assessed with cone-beam computed tomography. Angle Orthod.
Multiple Gingival Recession Defects Treated by the Vestibular Incision Subperiosteal Tun- 2012;82:67–74.
nel Access (VISTA) Procedure. Int J Periodontics Restorative Dent. 2019;39:687–695. 63. Pini Prato GP, Chambrone L. Orthodontic treatment in periodontal patients: the use of
31. Gil A, Bakhshalian N, Min S, Zadeh HH. Treatment of multiple recession defects with periodontal gold standards to overcome the "grey zone". J Periodontol. 2020;91:437–
vestibular incision subperiosteal tunnel access (VISTA): a retrospective pilot study uti- 441.
lizing digital analysis. J Esthet Restor Dent. 2018;30:572–579. 64. Wang CW, Yu SH, Mandelaris GA, et al. Is periodontal phenotype modification therapy
32. Tenenbaum H. A clinical study comparing the width of attached gingiva on the preva- beneficial for patients receiving orthodontic treatment? An American academy of peri-
lence of gingival recessions. J Clin Periodontol. 1982;9:86–92. odontology best evidence review. J Periodontol. 2020;91:299–310.
33. Camargo PM, Melnick PR, Kenney EB. The use of free gingival grafts for aesthetic pur- 65. Machado AW, MacGinnis M, Damis L, et al. Spontaneous improvement of gingival
poses. Periodontol. 2000;27:72–96. 2001. recession after correction of tooth positioning. Am J Orthod Dentofacial Orthop.
34. L€oe H, Anerud A, Boysen H. The natural history of periodontal disease in man: preva- 2014;145:828–835.
lence, severity, extent of gingival recession. J Periodontol. 1992;63:489–495. 66. Figueiredo MA, Romano FL, Feres MFN, et al. Effectiveness of Invisalign® aligners in
35. Prato GP, Rotundo R, Magnani C, et al. Viral etiology of gingival recession. A case the treatment of severe gingival recession: a case report. Korean J Orthod.
report. J Periodontol. 2002;73:110–114. 2021;51:293–300.
36. Parma-Benfenati S, Frigazzato PA, Ruben MP. The effect of restorative margins on the 67. Jacobs C, Katzorke M, Wiechmann D, et al. Single tooth torque correction in the lower
postsurgical development and nature of the periodontium. Part I. Int J Periodontics frontal area by a completely customized lingual appliance. Head Face Med.
Restorative Dent. 1985;5:30–51. 2017;13:18.
37. Donaldson D. Gingival recession associated with temporary crowns. J Periodontol. 68. Farret MM, Farret MM, da Luz VG, et al. Orthodontic treatment of a mandibular inci-
1973;44:691–696. sor fenestration resulting from a broken retainer. Am J Orthod Dentofac Orthop.
38. Khocht A, Simon G, Person P, et al. Gingival recession in relation to history of hard 2015;148:332–337.
toothbrush use. J Periodontol. 1993;64:900–905. 69. Engelking G, Zachrisson BU. Effects of incisor repositioning on monkey periodontium
39. Chambrone L, Chambrone LA. Gingival recessions caused by lip piercing: case report. after expansion through the cortical plate. Am J Orthod. 1982;82:23–32.
J Can Dent Assoc. 2003;6:505–508. 70. Pazera P, Fudalej P, Katsaros C. Severe complication of a bonded mandibular lingual
40. L€ost C. Depth of alveolar bone dehiscences in relation to gingival recessions. J Clin retainer. Am J Orthod Dentofac Orthop. 2012;142:406–409.
Periodontol. 1984;11:583–589. 71. Chambrone L, Avila-Ortiz G. Tissues: Critical Issues in Periodontal and Implant-Related
41. Mandelaris GA, Neiva R, Chambrone L. Cone-beam computed tomography and inter- Plastic and Reconstructive Surgery. Batavia: Quintessence Publishing Co Inc; 2022.
disciplinary dentofacial therapy: an American academy of periodontology best evi- 72. Tanaka OM, Avila AL, Silva GM, et al. The effects of orthodontic movement on a sube-
dence review focusing on risk assessment of the dentoalveolar bone changes pithelial connective tissue graft in the treatment of gingival recession. J Contemp Dent
influenced by tooth movement. J Periodontol. 2017;88:960–977. Pract. 2010;11:E073–E079.
42. Miller Jr PD. A classification of marginal tissue recession. Int J Periodontics Restorative 73. Bueno Rossy LA, Chambrone L. Management of multiple recession-type defects after
Dent. 1985;5:9–13. orthodontic therapy: a clinical report based on scientific evidence. Clin Adv Periodon-
43. Cortellini P, Bissada NF. Mucogingival conditions in the natural dentition: narrative tics. 2016;6:70–75.
review, case definitions, and diagnostic considerations. J Periodontol. 2018;89(1): 74. Kloukos D, Eliades T, Sculean A, et al. Indication and timing of soft tissue augmenta-
S204–S213. Suppl. tion at maxillary and mandibular incisors in orthodontic patients. A systematic review.
44. Pini Prato G, Di Gianfilippo R, Pannuti CM, et al. Diagnostic reproducibility of the Eur J Orthod. 2014;36:442–449.
2018 classification of gingival recession defects and gingival phenotype: a multicenter 75. Holmes HD, Tennant M, Goonewardene MS. Augmentation of faciolingual gingival
inter- and intra-examiner agreement study. J Periodontol. 2018. In press. dimensions with free connective tissue grafts before labial orthodontic tooth move-
45. Cairo F, Nieri M, Cincinelli S, et al. The interproximal clinical attachment level to clas- ment: an experimental study with a canine model. Am J Orthod Dentofacial Orthop.
sify gingival recessions and predict root coverage outcomes: an explorative and reli- 2005;127:562–572.
ability study. J Clin Periodontol. 2011;38:661–666. 76. Mehta L, Tewari S, Sharma R, et al. Assessment of the effect of orthodontic treatment
46. Chambrone L, Tatakis DN. Long-term outcomes of untreated buccal gingival reces- on the stability of pre-orthodontic recession coverage by connective tissue graft: a ran-
sions: a systematic review and meta-analysis. J Periodontol. 2016;87:796–808. domized controlled clinical trial. Quintessence Int. 2022;53:236–248.
47. Baer PN, Benjamin SD. Gingival grafts: a historical note. J Periodontol. 1981;52:206– 77. Zhang T, Zhang L, Li M, et al. Morphological changes in alveolar bone thickness and
207. height after orthodontic proclination or labial movement combined with autogenous
48. Stuhr S, N€ or F, Gaya L, et al. Histologic assessment and gene expression analysis of soft tissue grafting: a CBCT evaluation. BMC Oral Health. 2023;23:218.
intraoral soft tissue graft donor sites. J Clin Periodontol. 2023;50:1360−1370. 78. Kan JY, Morimoto T, Rungcharassaeng K, Roe P, Smith DH. Gingival biotype assess-
49. Couso-Queiruga E, Gonzalez-Martin O, Stuhr S, et al. Comparative histological evalua- ment in the esthetic zone: visual versus direct measurement. Int J Periodontics Restor-
tion of intra- and extraorally de-epithelialized connective tissue graft samples har- ative Dent. 2010;30:237–243.
vested from the posterior palate region. J Periodontol. In press.

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