GINGIVAL RECESSION IN RELATION TO MUCOGINGIVAL DEFORMITIES AND OTHER PREDISPOSING FACTORS AFFECT FEMALES IN LOWER ESTHETIC ZONE

Manal M. Al-Hajrilimage, Baleegh A. Al-Kadasi2image, Mohammed A. Al-Wesabi3image, 

Haifa M. Sharaf Aldeen1image, Sarah Al-Rai4image

1Oral Diagnosis Periodontology & Oral Radiology Department. Faculty of Dentistry Sana`a University, Yemen.

2Oral Medicine & Oral Diagnosis Department. Faculty of Dentistry, Ibb University, Yemen.

3Faculty of Dentistry, University of science and technology. Sana a, Yemen. 

4Conservative and Preventive Department. Faculty of Dentistry, Saba University, Yemen.

 

ABSTRACT 

Background: Gingival recession (GR) is one of the most common esthetic problems affecting the middle and older aged peoples.  GR can lead to many changes as root caries, hypersensitivity, erosions, abrasions, plaque retention and aesthetic dissatisfaction. This study aimed to evaluate the prevalence of gingival recession in relation to mucogingival deformities in lower esthetic zone. Methods: A cross-sectional study was done on a sample of 290 females. The participants were interviewed for personal habits and examined for intraoral distribution of gingival recession and its various predisposing factors.

 Results: The prevalence of gingival recession in lower anterior teeth was 234, 80.69 %.Around half of the participants had Millers' class I GR (n=146, 49%), thin gingival phenotype (n=168, 56.9 %), mucosal and gingival labial frenum attachment (n=132, 44.7%, n=148, 50.2%). Most of the participants had a sufficient attached gingiva (n=246, 83.4%) and normal vestibular depth (n=278, 94.2%). GR were statistically significant with vestibular depth, gingival biotype and attached gingiva (P≤0.05).

Conclusion: Gingival recession in lower aesthetics zone was high in females especially Miller class I gingival recession due to thin gingival phenotypes. Most of Yemeni females have adequate attached gingiva, normal vestibular depth with a frequent mucosallabial frenum in lower anterior teeth. 

Keywords: Esthetic, gingival recession, mucogingival deformities.

INTRODUCTION

 

Gingival recession (GR) is one of the most common esthetic problems affecting the middle and older aged peoples [1].  GR can lead to many clinical changes as root caries, tooth hypersensitivity, erosions, abrasions, plaque retention and aesthetic dissatisfaction [2]. GR may be localized or generalized [3,4]. There are many classifications of GR; however, Miller’s classification (1985) is still the most commonly used until now [5]. Plaque, calculus, poor and inadequate tooth brushing, iatrogenic factors (as prosthetic or orthodontic treatment)and anatomical factors or muco-gingival deformities are the most etiological factors of GR [6,7].

Armitage’s in 1999 classified the mucogingival deformities as developmental or acquired and conditional deformities [8]. Recently in 2018, mucogingival deformities were classified as:  gingival recession, low vestibular depth,lack of keratinized gingiva, , aberrant frenum position, abnormal gingival color and gingival excess [9]. Insufficient attached gingiva can not maintain gingival health in patients with poor oral hygiene. Many studies mentioned the importance of
 keratinized tissue and attached gingivain maintaining periodontal health with optimal plaque control [10-14]. 

Gingival biotype or phenotype was classified into thin and thick phenotype [11].  Thin gingival biotypewas most prominent in females when compared to males [12]. Gingiva of anterior teeth are at greater risk of recession especially when it has a thin periodontal phenotype and less or absence of attached gingiva [13].  Gingival phenotype could be evaluated by many methods invasive and noninvasive. These methods includevisual evaluation, needlesinjection, probe transparency, histological sections, transgingival probing, cephalometric radiographs, ultrasonic devicesand CBCT [14].  

GR is an issue that has its clinical importance in dental field. Many studies had evaluated the prevalence and predisposing factors of GR [15,17,18]. There are different factors that play role in gingival recession as age, plaque, tobacco consumption, trauma from occlusion, , aggressive tooth brushing, high frenal attachment, mal tooth position, excessive tooth movement by orthodontic forces, improper designed partial denture, bad restorations and calculus [16,20]. Several studies showed different sites of GR with increase in the lower incisors area [17,19]. 

Early detection and diagnosisof GR prevent tooth loss in future. Prevention of tooth loss depends mainly on periodic survey of the prevalence and risk factors that
 lead to the GR. Up to our knowledge, there is no study showed the GR prevalence and its predisposing factors in lower esthetic zone in Yemeni females which is important for esthetic and health. Hence, this study aims to evaluate the prevalence of gingival recession in relation to mucogingival deformities in lower esthetic zone and its predisposing factors in Yemeni females.

 

METHODS 

 

Study subjects. A cross sectional study was done on patients attended the department of oral medicine, oral diagnosis, periodontology and Oral radiology, Faculty of Dentistry, Sana’a University. A study was conducted over a period of two years (March 2017-March 2019). 

Sample size. The sample size for this study was estimated by using G*power 3.1.2.9 program with 0.3 effect size and  95% power gave a sample of  290 females in the age group between 17 and 60 years. 

Data collection. The study was designed following STROBE guidelines and conducted in adherence to Declaration of Helsinki. The study protocol was approved by the Ethical Committee of the Faculty of Medicine and Health Sciences, Sana a University, Yemen. The study was explained to the patients and informed consents were obtained. Inclusion criteria include all females aged from 17-60 year-old attended to Dental Teaching Clinic, Sana’a University. While exclusion criteria include females who had fixed or partial prostheses and/or orthodontic appliance which could be causative factors for GR.

A single calibrated examiner [HS] filled the questionnaire of demographic data by interviewing the participants. This questionnaire includes the following data: age, level of education, smoking habit, khat chewing habit, oral hygiene practices, medical and dental history. All females were clinically examined under adequate illumination using front surface mouth mirror, curved sharp sickle explorer (standard explorer), and William's graduated periodontal probe. Measuring gingival recessions (the distance of recession is measured from the cemento-enamel junction to gingival margin) on the labial, mesial, distal and lingual surfaces of lower anterior teeth as well as measuring gingival recession according to the Miller’s classification of marginal tissue recession [21]. In addition, gingival index, plaque index and pocket depth were evaluated in order to determine the diagnosis of periodontal diseases according to the periodontal diseases classification in 1999 [22]. Tension and rolling test was used to confirm the adequacy of the attached gingiva width. 

Gingival phenotypes were assessed on the basis of visual method by showing probe transgingival probing method with no.15 K-file was pierced at a 90º angle at three points i.e. distal,mesial and mid-facial. Thick biotypewhen gingival thickness more than1.5 mm while thin biotype is less than 1.5 mm. Position of lower labial frenum (mucosal or gingival or papillary, papillary penetrating), and vestibular depth (normal or shallow)were recorded [16]. Kappa scores higher than 0.9 were attained for intra-examine calibration exercises for identifying periodontal clinical parameters.

Statistical analysis 

Data analysis was performed for the collected data by using Chi-square test and Phi and Cramer's V Coefficient. Data were entered and analyzed using SPSS Statistics version 22.0, IBM United States Software.

 

RESULTS

 

The overall study sample was 290 female patients. Most of the sample have GR in the lower anterior teeth (n=234, 80.69 %), while the rest of participants were GR free patients (n=56, 19.31%).  Most of the participants (n=160, 55.0%) were at the age group of 20 -35 year-old. Regular tooth brushing was reported by most of the study sample (n=202, 68.5%). A high percentage of the study sample were non-smoker and non-khat chewer and free from systemic diseases (n=254,86.1%, n=180, 61.0 %, n=261,88.5 %, respectively). Characteristics of the study sample is shown in Table 1. Millers' class I GR was founded in about half of the sample (n=146, 49%), the second most prevalent type of recession was Millers' class III (n=60, 20.3%). Thin gingival phenotype was founded in about half of participants (n=168, 56.9%). Most of the participants had a sufficient attached gingiva (n=246, 83.4%). Characteristics of mucogingival area is shown in Table 2. Majority of teeth had a gingival and mucosal lower labial frenum attachment. Most of the teeth has normal vestibular depth, thin gingival biotype and sufficient attached gingiva as shown in Table 3. 

GR were statistically significant with vestibular depth, gingival biotype and attached gingiva (P≤0.05). However, GR was not statistically significant with lower labial frenumattachemnt. Relationship between GR and gingival soft tissue is described in Table 4.

 

DISCUSSION

 

GR can be localized or generalized and can be
associated with one or more surfaces [1]. Mandibular anterior teeth are more affected by GR than maxillaryanterior teeth as observed in previous investigations [13]. Mandibular keratinized mucosa was lesser than maxillary keratinized mucosa, this strong correlation has been observed between lower incisors and GR[12]. The concept of multiple predisposing factors in the etiology of the GR was supported by many longitudinal studies [23]. The early diagnosis of the etiological factors of GR may help in prevention and treatment needs.

For this reason, this study aims to evaluate the prevalence and predisposing factors of GR in lower esthetic zone in Yemeni females. In this study, it was found that the  prevalence of GR in the study was 80.69%, and these findings are consistent with the previous studies Checchi et al., and Albandar et al., [24,  26]. Most of GR was Millers' class I GR which was founded in about half of the sample (n=146, 49%), the second most prevalent type of recession was Millers' class III (n=60, 20.3%) similar to Myrthi et al., 2015 [15] in contrast to Sarfati et al.,  2010 study, who founds that the majority of cases has Miller’s class I, II [16].GR is less common in young adults although its frequency increases with age. In this study, most affected females (n=160, 55.0%)  were at the age group of 20 -35 year-old, and these findings are consistent with the previous studies  Albandar et al.,  and Ravipudi et al., [26, 27].  Most of them were regular tooth brushing (n=202, 68.5%) and non-smoker and non-khat chewer (n=254, 86.1%, n=180, 61.0 %; respectively). In the present study, about half of the cases (n=168, 56.9%) had thin gingival phenotype at all teeth examined, whereas the majority of the cases (n=246, 83.4%) had a sufficient attached gingival width. There is a significant (P<0.05) association between the adequacy of the attached gingiva and  GR which was similar to the findings of Wennström et al., [28]. In contrary, Stoner and Mazdyasna [29] and Nguyen-Hieu et al., [30] found that lack of an adequate zone of attached gingiva result in increased incidence of GR so it is supposed that the thin gingival biotype of Yemeni participants is the strongest risk factor for GR in lower aesthetics zone. Majority of teeth had gingival and mucosal lower labial frenum attachment and most of the teeth has normal vestibular depth, thin gingival biotype and sufficient attached gingiva.GR may be related to different etiologic factors that were not reported in this study asmalpositioning of teeth, prominent roots, thin labial alveolar bone, and trauma form tooth brushing
[31, 27]. There is a non significant association between type of frenal attachment and prevalence of GR (P<0.05) which is opposite to studies conducted by Toker and Ozdemir [32] and Mathur et al., [33]. However, this is similar to studies conducted by Tenenbaum [35] and Nguyen-Hieu et al.,
 [36] who proposed that GR is not associated with the
high frenal attachment. This is could be because of low number of papillary lower labial frenum.

 

CONCLUSION


 The results of this study showed the high prevalence of gingival recession in lower esthetics zone especially Miller class I gingival recession due to thin gingival phenotypes. Most of Yemeni females have adequate attached gingiva, normal vestibular depth and mucosal and gingival labial frenum attachment. 

 

ACKNOWLEDGEMENTS

 

The authors thank all dental staff at Sana`a university for facilitating the examination process of the patients, and the dental patients for their participation in the study.

 

AUTHORS' CONTRIBUTIONS

 

A.M.M conceived the ideas; A.M. and A.B led the writing; S.H. collected the data and A.M analysed the data. All Authors read and approved the manuscript.

CONFLICT OF INTEREST

 

The authors declare that they have no conflict of interest.

 

REFERENCES 

 

  1. The American Academy of Periodontology. Glossary of periodontal terms, 4th Chicago IL: The American Academy of Periodontology 2001; 200:44.
  2. Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. The J American Dental Assoc 2003;134:220-5.https://doi.org/10.14219/jada.archive.2003.0137
  1. Khosya B, Devaraj CG. Etiology and severity of different grades of gingival recession in adult population. Natl J Med Res 2014; 4:189-192.
  2. Chambrone LA, Chambrone L. Subepithelial connective tissue grafts in the treatment of multiple recession-type defects. J Periodontol 2006; 77:909–16.https://doi.org/10.1902/jop.2006.050249
  1. AJ Miller, JA Brunelle, JP. Carlos, LJ Brown, H Loe. Oral Health of United States Adults. The National Survey of Oral Health in U.S. Employed Adults and Seniors: 1985-1986; NIH publication no. 87-2868.
  2. Susin C, Haas AN, Oppermann RV, Haugejorden O, Albandar JM. Gingival recession: epidemiology and risk indicators in a representative urban Brazilian population. J Periodontol 2004; 75:1377–86.https://doi.org/10.1902/jop.2004.75.10.1377
  1. Ravipudi S, Psg P, Victor D. Gingival Recession: Short literature review on etiology, classifications and various treatment options. J Pharm Sci Res. 2017; 9:215-220.
  2. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4: 1-6. https://doi.org/10.1902/annals.1999.4.1.1
  3. PierpaoloCortellini, Nabil F, Bissada. Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations. J Periodontol 2018;89:204–213. https://doi.org/10.1002/JPER.16-0671
  4. Kim DM, Neiva R. Periodontal soft tissue non-root coverage procedures: A systematic review from the AAP regeneration workshop. J Periodontol 2015;86:S56–S72.https://doi.org/10.1902/jop.2015.130684
  1. Fu JH, Yeh CY, Chan HL, Tatarakis N, Leong DJ, Wang HL. Tissue biotype and its relation to the underlying bone morphology. J Periodontol 2010;81:569-574.https://doi.org/10.1902/jop.2009.090591
  1. Marini MG, Greghi SL, Passanezi E, Sant’ana LC. Gingival recession prevalence, extension and severity in adults. J App Oral Sci 2004;12:250- 5.https://doi.org/10.1590/s1678-77572004000300017
  1. Kundapur PP, Bhat KM, Bhat GS. Association of trauma from occlusion with localized gingival recession in mandibular anterior teeth. DRJ 2009; 6:71-4.PMID: 21528034
  1. Barriviera M, Duarte WR, Janua’rio AL, Faber J, Bezerra AC. A new method to assess and measure palatal masticatory mucosa by cone-beam computerized tomography. J Clin Periodontol 2009; 36:564-568.https://doi.org/10.1111/j.1600-051X.2009.01422.x
  1. Mythri S, Arunkumar SM, Hegde S, Rajesh SK, Munaz M, Ashwin D. Etiology and occurrence of gingival recession - An epidemiological study. J Indian Soc Periodontol 2015;19:671-5. https://doi.org/10.4103/0972-124X.156881
  2. Sarfati Al, Bourgeois D, Katsahian S, Mora Fr, Bouchard Ph. Risk assessment for buccal gingival recession defects in an adult population. J Periodontol 2010;81:1419-1425.https://doi.org/10.1902/jop.2010.100102
  1. Albandar JM, Kingman A. Gingival recession, gingival bleeding and dental calculus in adults 30 years of age and older in the United States, 1988-1994. J Periodontol 1999;70:30-43. https://doi.org/10.1902/jop.1999.70.1.30
  2. Gornman WJ. Prevalence and etiology of gingival recession. J Periodontol 1967;38:316-322.https://doi.org/10.1902/jop.1967.38.4.316
  1. Esfahrood ZR, Kadkhodazadeh M, Talebi Ardakani MR. Gingival biotype: A review. Gen Dent 2013;61:14-7.PMID: 23823337
  1. K Pradeep, P Rajababu, Satyanarayana D, Sagar V. Gingival recession: Review and Strategies in Treatment of Recession. Case Reports in Dentistry 2012.https://doi.org/10.1155/2012/563421
  1. Miller PD. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985;5:8–13.PMID: 3858267
  1. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999; 4:1-6
  2. Löe H, Ånerud Å, Boysen H. The natural history of periodontal disease in man: prevalence, severity, and extent of gingival recession. J Periodont 1992; 63:489-95.https://doi.org/10.1902/jop.1992.63.6.489
  1. Checchi L, Daprile G, Gatto MR, Pelliccioni GA. Gingival recession and toothbrushing in an Italian School of Dentistry: A pilot study. J Clin Periodontol 1999;26:276–80.https://doi.org/10.1034/j.1600-051x.1999.260502.x
  1. Slutzkey S, Levin L. Gingival recession in young adults: occurrence, severity, and relationship to past orthodontic treatment and oral piercing. J Orthod Dentofacial Orthop 2008;134:652–656.https://doi.org/10.1016/j.ajodo.2007.02.054
  1. Albandar JM, Kingman A. Gingival recession, gingival bleeding and dental calculus in adults 30 years of age and older in the United States, 1988-1994. J Periodontol 1999;70:30-43.
  2. Ravipudi S, Appukuttan D, Prakash PSG, Victor DJ. Gingival Recession: Short Literature review on etiology, classifications and various treatment options. J Pharm Sci Res 2017;  9,215-220.
  3. Wennström JL, Zucchelli G. Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures? J Clin Periodont 1996; 23:770-777.https://doi.org/10.1111/j.1600-051x.1996.tb00608.x
  1. Stoner JE, Mazdyansna S. Gingival recession in the lower incisor region of 15 year old subjects. J Periodontol 1980;51:74-76. https://doi.org/10.1902/jop.1980.51.2.74
  2. Nguyen-Hieu T, Ha Thi BD, Do Thu H, Tran Giao H. Gingival recession associated with predisposing factors in young Vietnamese: A pilot study. Oral Health Dent Manag 2012; 11:134-144. PMID: 22976574
  3. Khosya B, Devaraj CG. Etiology and severity of different grades of gingival recession in adult population. Natl J Med Res 2014; 4:189-192.
  4. Toker H, Ozdemir H. Gingival recession: Epidemiology and risk indicators in a university dental hospital in Turkey. Int J Dent Hyg 2009; 7:115–20.https://doi.org/10.1111/j.1601-5037.2008.00348.x
  1. Mathur A, Jain M, Jain K, Samar M, Goutham B, Swamy PD, Kulkarni S. Gingival recession in school kids aged 10-15 years in Udaipur. India J Indian Soc Periodontol 2009; 13:16–20. https://doi.org/10.4103/0972-124X.51889
  2. Lafzi A, Abolfazli N, Eskandari A. Assessment of the etiologic factors of gingival recession in a group of patients in Northwest Iran. J Dental Res Dental Clinics Dental Prospects 2009; 3:90–3.https://doi.org/10.5681/joddd.2009.023
  1. Tenenbaum H, Tenenbaum N. A clinical study of the width of the attached gingiva in the deciduous, transitional and permanent dentitions. J Clin Periodontol 1986; 13:270-275.https://doi.org/10.1111/j.1600-051x.1986.tb02221.x
  1. Nguyen-Hieu T, Ha Thi BD, Do Thu H, Tran Giao H. Gingival recession associated with predisposing factors in young Vietnamese: A pilot study. Oral Health Dent Manag 2012; 11:134-44.