Orthodontic-Restorative Interface | OPEN

CLINICAL

The role of orthodontics in the prevention and

management of gingival recession
Padhraig S. Fleming*1,2 and James Andrews3

Key points
Thin periodontal phenotype is associated with Careful space creation and judicious and flexible use Carefully-planned orthodontics is generally
increased risk of recession during orthodontic of mechanics are essential in ensuring optimal tooth compatible with periodontal health even in
treatment necessitating detailed planning positioning in order to ensure optimal long-term susceptible patients. Moreover, orthodontics in
and indicating combined orthodontic- outcomes. isolation or in combination with muco-gingival
periodontal input in selected cases with a clear surgery may contribute to enhanced periodontal
understanding of the optimal nature and timing outcomes.
of interventions an imperative.

Abstract
Careful management of orthodontic patients presenting with thin periodontal phenotype is paramount. Combined
orthodontic-periodontal input is helpful both in terms of diagnosis and stabilisation but also to coordinate care. Well-
executed orthodontics offers the potential to safeguard periodontal health but also to induce significant aesthetic
improvement either in isolation or combined with increasingly predictable muco-gingival procedures.

Introduction induce unwanted recession particularly in this attachment levels relative to the inter-proximal
cohort. There is also an increased risk associated bone but also the width of the attached gingiva
Gingival recession involves exposure of the root with ambitious tooth movement outside the and gingival thickness with 1 mm thresholds for
surfaces due to apical migration of the gingival alveolar boundaries in all patients. In growing the latter two parameters.4
margin relative to the cemento-enamel junction. patients, this may not be obvious during or
The prevalence of recession is age-related with even immediately after treatment; however, this Orthodontic planning and recession
a predilection among adults particularly over approach may represent a significant risk factor
the age of 50 years.1 Recession is inextricably for recession in adulthood.2 Conversely, carefully Orthodontic treatment is proven to induce
linked with hard tissue loss with 1 mm of planned treatment can be used as a means of predictable aesthetic improvement. This may
recession associated with 2.8 mm of bone preventing deterioration or indeed in addressing translate into social and socio-psychological
dehiscence.2 Each further 1 mm increment recession either independently or in combination benefit particularly in those with more salient
has been linked to a commensurate (0.98 mm) with periodontal therapy. features of malocclusion in the aesthetic zone.5,6,7
amount of dehiscence.2 There are a myriad of There is, however, associated risk including: root
contributors including periodontal disease and Diagnosis and classification resorption, demineralisation and periodontal
hygiene measures allied to maturational changes issues. The potential aesthetic benefit of
including declining vascularity and collagen Recession is typically diagnosed clinically and treatment should therefore be considered in this
content in gingival tissues. The increasing traction may be associated with aesthetic impact as well as context with risk factors for deleterious effects
of adult orthodontics has prompted an onus on sensitivity. Clinical parameters include recession being identified and mitigated.
the management of both pre-existing recession depth, probing pocket depths, clinical attachment Gingival recession may emanate from
and susceptible patients within routine clinical level, and width and thickness of keratinised undermined periodontal support with the
practice. Orthodontic treatment can undoubtedly tissue. Supplementary imaging including two- cortical plates being largely immutable.
dimensional intra-oral views and cone-beam This can be potentiated by significant
1
Chair/Professor of Orthodontics, School of Dental Science, computed tomography (CBCT) may provide anteroposterior and transverse dento-alveolar
Dublin Dental University Hospital, The University of Dublin,
additional information on inter-proximal bone change during treatment but also during the
Trinity College Dublin, Ireland; 2Honorary Professor of
Orthodontics, Queen Mary University of London, UK; heights, bone volume and topography including resolution of crowding, which may induce
3
Specialist in Orthodontics, Perth, Western Australia. the presence of fenestration and dehiscence. incisal proclination and transverse expansion.8
*Correspondence to: Padhraig S. Fleming
Email address: padhraig.fleming@dental.tcd.ie An accepted classification of recession based Significant arch lengthening can lead to
Refereed Paper.
on the gingival margin height relative to the resorption of the cortical plates resulting in
Submitted 8 April 2024 mucogingival junction and accounting for fenestration and dehiscence with the latter
Revised 28 June 2024 inter-proximal bone and soft tissue loss was involving the alveolar margin. It is, however,
Accepted 2 July 2024 proposed by Miller.3 This has since been updated noteworthy that the prevalence of both labial
https://doi.org/10.1038/s41415-024-7781-1
to encompass both mid-buccal or mid-lingual fenestration and dehiscence is high in untreated

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Fig. 1 A crowded dentition with palatal

displacement of 12 and lingual positioning
of 42 and 31. Note the excess gingival tissue
present. Conversely, both 41 and 32 are
labially placed with associated recession

subjects at 36% and 20%, respectively.9 Based

on CBCT, fenestrations were more common Fig. 2 a, b) Both 41 and 32 were labially displaced, reflecting lower anterior malalignment.
c, d) Following simple re-alignment involving judicious local space creation, the lower
on the canine teeth and most prevalent in the
anteriors were aligned with improvement in the gingival appearance reflecting repositioning
apical third but involved the entire root in 8.4% within the alveolar housing
with palatal dehiscence detected in less than
2% in the anterior maxilla.9
Thresholds for safe orthodontic tooth
movements are imposed both by the
constraints related to the alveolar housing,
cortical plates and investing soft tissues. In
addition to periodontal compromise, violation
of these limits may risk both root resorption
and instability.10 It is accepted that a narrow
band of as little as 1 mm of keratinised attached
gingival tissue may be sufficient to withstand
orthodontic stresses.11,12 Equally, by preserving
the position of the teeth within the alveolar
Fig. 3 a, b) Alveolar plate thickness (mm) from 3 mm to 8 mm apical to the cemento-enamel
process, the risk of recession is minimised.11,12
junction. Note that the labial plates are thinner than palatal particularly in the inter-first
premolar region19
Periodontal phenotype

Recession is particularly likely in those with thin Orthodontic diagnosis in the instructive in mapping alveolar boundaries
periodontal biotype or phenotype. The term susceptible periodontium highlighting that cortical plates are generally
‘phenotype’ has been advanced as biotype reflects thin even in adolescence but particularly on
genetically predetermined appearance, while Tailored orthodontic diagnosis has been the labial aspects of the teeth.19 Cortical plates
phenotype might also encompass environmental facilitated by the advent and increasing tend to be particularly thin in the labial inter-
influences including orthodontics, mucogingival adoption of CBCT. While blanket prescription canine region in both upper and lower arches
procedures and overhanging restorations.13 A of cone-beam imaging remains exceptional (Fig. 3). Deleterious change may therefore be
thin phenotype can be diagnosed visually but also governed by dose limitation, 17 detailed risked with significant mandibular incisor
during probing with visibility of the periodontal imaging may help to isolate patients or sites proclination, in particular. Based on analysis
probe expected with a thickness below 1 mm.14 that are more susceptible to recession. It is of 49 subjects using baseline and post-
Vertical facial dimension may be associated with accepted, however, that periodontal ligaments treatment CBCTs, Matsumoto et al. (2020)20
phenotype although this has not uniformly been spaces of 200 μm or less may not be detectable reported a high prevalence of dehiscence. In
demonstrated in younger adults and orthodontic risking false positive findings of fenestration an adolescent sample with a mean age of 11.2
patients.15,16 From a clinical perspective, it is or dehiscence. Moreover, image resolution is years, dehiscence was present at baseline on
important to appreciate the relationship between affected by patient motion, reduced spatial 32% of mandibular incisors in male patients
tooth position and gingival coverage. Specifically, resolution at the periphery and voxel size and 24% of teeth in female patients. These
labially-displaced and rotated teeth may lack with a smaller voxel size (<100 μm) leading prevalence rates almost doubled (to 58% in
gingival coverage labially, while lingually- to enhanced resolution but with an attendant male and 45% in female patients) following
positioned teeth may present with bunching of increase in radiation dosage.17,18 treatment. Proclination of the mandibular
tissue labially (Figures 1 and 2). From a research perspective, CBCT has been incisors predisposed to dehiscence, with a

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Fig. 4 An adult male had a Class III malocclusion on a skeletal III pattern with anterior
displacement on closure. a, b) There was a thin periodontal phenotype with pre-existing
recession on the maxillary and mandibular anteriors. Controlled advancement of the crowns
of upper left central and lateral incisors was planned with retraction of the lower incisor
crowns also required to camouflage the malocclusion. c, d) Connective tissue grafts were
undertaken in the upper left quadrant and lower incisor region labially during treatment.
e, f) Full occlusal correction was achieved with the overjet normalised. Further grafting in
the upper right quadrant may be considered in time.

50% probability of 2 mm of vertical bone layer, and an increase in the number and density aesthetic regions including the labial aspect of
loss following lower incisor proclination of of collagen bundles in the lamina propria. This the maxillary incisors.24
8 degrees.20 translates into increased width and thickness of
While CBCT may be particularly the keratinised tissue enhancing the prospect Combined orthodontic-periodontal
instructive in certain situations, adjunctive of complete root coverage and gingival stability planning
use remains best reserved for more susceptible with five-year follow-up indicating that a
patients and sites. In the absence of three- minimum threshold of 2 mm width of attached The principles underpinning orthodontic
dimensional volumetric information, the gingiva and 1 mm thickness is required to treatment generally apply to those with
recommended scope of tooth movement can maintain marginal stability in both treated and susceptible periodontal phenotype. In
only be approximated. However, significant untreated groups.22 particular, however, the risk of deleterious
recession on both labial and lingual aspects in Evidence supporting the effectiveness of change associated with injudicious arch
the presence of a thin periodontal phenotype root coverage procedures is clear-cut, with lengthening by proclination or expansion
may contra-indicate significant tooth subepithelial connective tissue grafting in is paramount. Moreover, a tooth-specific
movement without adjunctive periodontal conjunction with coronally advanced flaps assessment of the risks of treatment may be
treatment. Conversely, recession confined to being indicated both for single and multiple warranted based both on the features of the
a single surface may dictate a more assertive recession sites based on follow-up of up to malocclusion, patient concerns, individual
approach. 12 months.23 Factors influencing the scope susceptibility and local anatomical factors.
and remit of subepithelial grafting include the Inter-disciplinary evaluation may be
Surgical root coverage procedures location and number of defects, the thickness appropriate in patients with mucogingival
and width of the flap, and the volume of graft deformities with periodontal health before the
Gingival augmentation procedures include required from donor sites including the palate commencement of treatment a prerequisite.
flaps and grafts. Significant advancements and tuberosity. Where gingival augmentation procedures
in the predictability of graft procedures have In instances where the width and thickness of are performed, wound healing should be
occurred in recent years with subepithelial gingival tissue or keratinised tissue rather than permitted over a period of at least six weeks
connective tissue grafts from intra-oral sites, root coverage is required, free gingival grafts are and three months following free gingival
the use of novel soft tissue substitutes, and preferable with subepithelial grafting using a grafting and sub-epithelial connective
periodontal soft tissue phenotype modification tunnelling approach also proven effective.22 Free tissue grafting, respectively. Thereafter, the
gaining increased traction. 21 Phenotypic gingival grafts are best reserved for sites with impact of buccal or labial orthodontic tooth
modification includes histologic and lower aesthetic premium including mandibular movement should be considered with regular
clinical changes induced by soft tissue grafts sites due to changes in texture and lighter colour. periodontal maintenance and joint post-
characterised by thickening of the epithelial Subepithelial grafts may be better suited to more treatment evaluation recommended (Fig. 4).25

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Fig. 5 a, b) A 35-year-old woman presented with dual-arch crowding with thin periodontal phenotype and moderate lower anterior crowding.
c) The lower right lateral incisor was labially excluded with significant associated recession. d, e) A decision was made to extract this tooth in
order to avoid arch lengthening with a limited-objective plan to align both arches accepting a slight residual overjet

Fig. 6 a, b) Bimaxillary proclination with associated crowding a patient with thin periodontal phenotype. c, d, e) Treatment was undertaken
on an extraction basis with maximal anchorage in order to address the crowding and protrusion while retracing the dentition into the alveolar
housing. f, g, h, i) A favourable gingival response to treatment was observed

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Clinical data underpinning the appropriate

staging of periodontal and orthodontic
therapy in the presence of muco-gingival
defects are lacking. Undoubtedly, roots
positioned labial to the alveolar housing
should initially be aligned and appropriately
torqued before soft tissue augmentation.
Conversely, however, in the presence of a
particularly thin alveolus, this procedure
may risk the creation of a dehiscence on
the lingual aspect.21 The institution of root
coverage procedures before orthodontics
has been associated with improved stability
of marginal levels and an improved width
of keratinised tissue relative to deferral.26 It
therefore appears reasonable to recommend
prior grafting procedures with recession
defects characterised by minimal (<1 mm)
width of attached gingiva and gingival
thickness. 21 Exceptions to this approach
include extra-alveolar root positioning and
excessively thin alveolar dimensions.

Orthodontic planning and mechanics

Space creation
As in the case of Stage III and Stage IV Fig. 7 A 15-year-old male patient had been undergoing extraction-based orthodontic
periodontal disease, the correct timing treatment in another practice. a, b, c) Significant flaring of the maxillary incisors had
of space creation is an imperative. In occurred with loss of torque and impingement of the apices on the lingual cortex. d, e, f) The
particular, uncontrolled arch lengthening existing fixed appliances were replaced with inversion of the maxillary incisal attachments
introducing labial root torque, control of mesial angulation in the maxillary canines and
due to insufficient space may lead to
sparing space creation being used to upright the incisors within cancellous bone over a
displacement of the roots from the alveolar period of eight months
housing, further compromising gingival
aesthetics and periodontal health (Fig. 5).
Conversely, appropriate space creation and wire bending and the use of auxiliaries. including wire-bending (Fig. 8), proprietary
anchorage management may be harnessed In view of the anatomical factors, local adjuncts (eg Goodman springs) and use of
to enhance gingival support by retracting variations are typically required in the other auxiliaries e.g., strategic positioning of
the dentition into enhanced regions of bony anterior region. Specifically, the torque elastomeric chain occlusal to the brackets to
support (Fig. 6). Formal quantification of prescription on the mandibular incisors introduce retroclination.
space requirements is therefore advisable can be reversed; for example, by inversion
in order both to mitigate either under- of MBT incisor attachments introducing Gingival response
or over-estimation of space needs. 27 The (up to six degrees of ) lingual root torque. Orthodontic treatment may help to harmonise
latter may also be problematic due to the Similarly, torque variations can be used gingival levels with local recession, in
risk of excessive treatment duration and in the maxillary incisor region to address particular, potentially impairing gingival
indeed failure to close extraction spaces. torque issues and related periodontal aesthetics. Local vertical correction of tooth
The likelihood of adjunctive use of inter- consequences (Fig. 7). These local variations position can contribute to levelling of gingival
proximal reduction to enhance gingival exert local effects following the engagement margins, although faithful movement of
aesthetics should also be accounted during of rectangular archwires. Increasing the gingival tissues cannot be guaranteed (Fig. 9).
extraction decisions. rigidity and dimensions of rectangular wires It is suggested that more gradual orthodontic
increases their potency with recognised movement favours commensurate movement
Local torque delivery geometric limitations associated with torque of the gingival apparatus, although stretching
Local torque delivery can be particularly expression in a horizontal bracket slot. These of gingival tissues in the presence of thinner
important in the presence of thin periodontal shortcomings are compounded by wire and periodontal phenotype may be particularly
phenotype promoting repositioning of the bracket flexibility, ligation mode, oversized uncertain. Notwithstanding this, marked
roots within the confines of cancellous bone. brackets and undersized slots. 28 On that improvements can be expected in most
This can be achieved with fixed appliances basis, a number of solutions not reliant instances with gingival tissues moving
or aligners with local bracket variations, on the bracket-archwire interface exist approximately 80% relative to the tooth.29

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Old extraction sites

Old extraction sites, particularly in the
presence of thin periodontal phenotype,
may present a significant impediment to
tooth movement. In particular, hour-glass
shaped deformity with little cancellous bone
inter-posed between the cortical plates are
likely to be most resistant. When coupled
with thin periodontal phenotype and pre-
existing recession, a decision may be made
to accept space locally or indeed to facilitate
prosthetic replacement. Alternatively, space
closure can be attempted with orthodontics
alone or indeed with adjunctive periodontal
treatments including bone grafting to
promote space closure.30,31 Nevertheless, it is
important to set realistic expectations in this
respect being responsive to lack of associated
Fig. 8 A transfer case presented with significant labial recession on lower right central incisor.
progress.
An inverted mandibular premolar attachment was placed on the tooth to promote lingual
root torque with an auxiliary wire formed in 0.018-inch stainless-steel added to augment this.
Conclusions Gingival grafting is planned following orthodontic treatment

Orthodontic treatment in the presence

of thin periodontal phenotype presents
a diagnostic and clinical challenge.
Specifically, combined orthodontic-
periodontal input may be helpful in
planning with strategic aims devised in
order to safeguard periodontal health
while producing acceptable orthodontic
outcomes. Periodontal surgical procedures
may be indicated before orthodontics
particularly in recession defects with
minimal (<1 mm) width of attached
gingiva and gingival thickness. With careful
planning, however, orthodontic treatment Fig. 9 a) A 32-year-old woman presented having had a history of trauma to the maxillary
may offer a valuable adjunct to periodontal right central incisor in adolescence. It had been assumed that this tooth was ankylosed with a
treatments in complementing orthodontic marked gingival asymmetry. b, c, d, e) Based on a clinical assessment, ankylosis was excluded
correction improving ‘pink aesthetics’ while and fixed appliances were placed to gradually extrude 11 with periodic repositioning of
the attachment, local extrusion bends and discing of the composite restoration to maintain
also reducing the risk of further periodontal
aesthetics and permit unimpeded extrusion. f) The tooth was extruded over a 12-month period
breakdown. with placement of an interim maxillary fixed retainer before definitive restorative work

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