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Volume 89,
Issue S1
Special Issue:
Proceedings of
2017 WORLD WORKSHOP  Free Access
the World
Workshop on
Mucogingival conditions in the natural the
Classi!cation of
dentition: Narrative review, case Periodontal and
de!nitions, and diagnostic Peri-Implant
Diseases and
considerations Conditions. Co-
edited by
Pierpaolo Cortellini, Nabil F. Bissada  Kenneth S.
Kornman and
First published: 21 June 2018 | Maurizio S.
https://doi.org/10.1002/JPER.16-0671 | Citations: 166 Tonetti. The
workshop was
The proceedings of the workshop were jointly and planned and
conducted
simultaneously published in the Journal of Periodontology and
jointly by the
Journal of Clinical Periodontology. American
Academy of
Abstract Periodontology
and the
European
Federation of
Background Periodontology
with !nancial
Mucogingival deformities, and gingival recession in support from
particular, are a group of conditions that a"ect a the American
Academy of
large number of patients. Since life expectancy is Periodontology
rising and people are retaining more teeth both Foundation,
gingival recession and the related damages to the Colgate,
Johnson &
root surface are likely to become more frequent. It is Johnson
therefore important to de#ne anatomic/morphologic Consumer Inc.,
Geistlich
characteristics of mucogingival lesions and other Biomaterials,
predisposing conditions or treatments that are likely SUNSTAR, and
Procter &
to be associated with occurrence of gingival
Gamble
recession. Professional
:
 Professional
Oral Health. All
Objectives manuscripts
were fully peer
reviewed
Mucogingival defects including gingival recession
June 2018
occur frequently in adults, have a tendency to
Pages S204-S213
increase with age, and occur in populations with
This article also
both high and low standards of oral hygiene. The
appears in:
root surface exposure is frequently associated with AAP Clinical and
impaired esthetics, dentinal hypersensitivity and Scienti#c Papers
carious and non-carious cervical lesions. The
objectives of this review are as follows (1) to propose
a clinically oriented classi#cation of the main    
mucogingival conditions, recession in particular; (2) Figures References Related Information

to de#ne the impact of these conditions in the areas

of esthetics, dentin hypersensitivity and root surface Recommended
alterations at the cervical area; and (3) to discuss the
impact of the clinical signs and symptoms associated Occlusal trauma and
with the development of gingival recessions on excessive occlusal
forces: Narrative
future periodontal health status.
review, case
de#nitions, and
Results diagnostic
considerations
An extensive literature search revealed the following
#ndings: 1) periodontal health can be maintained in Jingyuan Fan,
Jack G. Caton
most patients with optimal home care; 2) thin
periodontal biotypes are at greater risk for Journal of
developing gingival recession; 3) inadequate oral Periodontology

hygiene, orthodontic treatment, and cervical

restorations might increase the risk for the Periodontal
development of gingival recession; 4) in the absence manifestations of
of pathosis, monitoring speci#c sites seems to be the systemic diseases and
proper approach; 5) surgical intervention, either to developmental and
acquired conditions:
change the biotype and/or to cover roots, might be
Consensus report of
indicated when the risk for the development or workgroup 3 of the
progression of pathosis and associated root 2017 World Workshop
damages is increased and to satisfy the esthetic on the Classi#cation of
requirements of the patients. Periodontal and Peri‐
:
 requirements of the patients.
Implant Diseases and
Conditions
Conclusions
Søren Jepsen,
The clinical impact and the prevalence of conditions Jack G. Caton,
like root surface lesions, hypersensitivity, and patient Jasim M. Albandar,
Nabil F. Bissada,
esthetic concern associated with gingival recessions
Philippe Bouchard,
indicate the need to modify the 1999 classi#cation. Pierpaolo Cortellini,
The new classi#cation includes additional Korkud Demirel,

information, such as recession severity, dimension of

the gingiva (gingival biotype), presence/absence of
caries and non-carious cervical lesions, esthetic
concern of the patient, and presence/absence of
dentin hypersensitivity.

INTRODUCTION AND AIMS

Mucogingival deformities are a group of conditions that
a"ect a large number of patients. Classi#cation and
de#nitions are available in a previous review1 and in the
consensus report on mucogingival deformities and
conditions around teeth (Table 1).

Table 1. Mucogingival deformities and conditions

around teeth a

1. gingival/soft tissue recession

a. facial or lingual surfaces

b. interproximal (papillary)

2. lack of keratinized gingiva

3. decreased vestibular depth

4. aberrant frenum/muscle position

:
 5. gingival excess

a. pseudo-pocket
b. inconsistent gingival margin

c. excessive gingival display

d. gingival enlargement

6. abnormal color

a
(AAP 1999, Consensus Report)

Among the mucogingival deformities, lack of keratinized

tissue and gingival recession are the most common and
are the main focus of this review. A recent consensus
concluded that a minimum amount of keratinized tissue
is not needed to prevent attachment loss when good
conditions are present. However, attached gingiva is
important to maintain gingival health in patients with
suboptimal plaque control.2 Lack of keratinized tissue is
considered a predisposing factor for the development
of gingival recessions and in$ammation.2 Gingival
recession occurs frequently in adults, has a tendency to
increase with age,3 and occurs in populations with both
high and low standards of oral hygiene.4-6 Recent
surveys revealed that 88% of people aged ≥65 years and
50% of people aged 18 to 64 years have ≥1 site with
gingival recession.3 Several aspects of gingival recession
make it clinically signi#cant.3, 7, 8 The presence of
recession is esthetically unacceptable for many patients;
dentin hypersensitivity may occur; the denuded root
surfaces are exposed to the oral environment and may
be associated with carious and non-carious cervical
lesions (NCCL), such as abrasions or erosions.
:
 lesions (NCCL), such as abrasions or erosions.
Prevalence and severity of NCCL appear to increase with
age.9 Because life expectancy is rising and people are
retaining more teeth, both gingival recession and the
related damages to the root surface are likely to
become more frequent.

The focus of this review is to propose a clinically

oriented classi#cation of the mucogingival conditions,
especially gingival recession; and to de#ne the patient
and site impact of these conditions regarding esthetics,
dentinal hypersensitivity and root surface alterations at
the cervical area. Therefore, de#nition of the “normal”
mucogingival condition is the baseline to describe
“abnormalities”. The de#nition of anatomic and
morphologic characteristics of di"erent periodontal
biotypes and other predisposing conditions and
treatments will be presented. The third focus of this
review is to discuss the impact of the clinical signs and
symptoms associated with the development of gingival
recessions on future periodontal health status.

METHODS
This article is based mainly on the contribution of the
most recent systematic reviews and meta-analyses. In
addition, case report, case series, and randomized
clinical trials published more recently are included. The
authors critically evaluated the literature associated
with mucogingival deformities in general and gingival
recession in particular to answer the following most
common and clinically relevant questions: 1) Is thin
gingival biotype a condition associated with gingival
recession? 2) Is it still valid that a certain amount of
attached gingiva is necessary to maintain gingival health
and prevent gingival recession? 3) Is the thickness of the
:
 and prevent gingival recession? 3) Is the thickness of the
gingiva and underlying alveolar bone critical in
preventing gingival recession? 4) Does daily
toothbrushing cause gingival recession? 5) What is the
impact of intrasulcular restorative margin placement on
the development of gingival recession? 6) What is the
impact of orthodontic treatment on the development of
gingival recession? 7) Is progressive gingival recession
predictable? If so, could it be prevented by surgical
treatment? 8) What is the impact of the exposure to the
oral environment on the root surface in the cervical
area?

Information Sources
An extensive literature search was performed using the
following databases (searched from March to June
2016): 1) PubMed; 2) the Cochrane Oral Health Group
Specialized Trials Registry (the Cochrane Library); and 3)
hand searching of the Journal of Periodontology,
International Journal of Periodontics and Restorative
Dentistry, Journal of Clinical Periodontology, and Journal of
Periodontal Research.

Search
The following search terms were used to identify
relevant literature: 1) attached gingiva; 2) gingival
augmentation; 3) periodontal/gingival biotype; 4)
gingival recession; 5) keratinized tissue; 6) dentin
hypersensitivity 7) mucogingival therapy; 8) orthodontic
treatment; 9) patient reported outcome; 10) non-carious
cervical lesions; 11) cervical caries; and 12) restorative
margin.

NORMAL MUCOGINGIVAL
CONDITION
:
 CONDITION
De#nition
Within the individual variability of anatomy and
morphology “normal mucogingival condition” can be
de#ned as the “absence of pathosis (i.e. gingival
recession, gingivitis, periodontitis)”. There will be
extreme conditions without obvious pathosis in which
the deviation from what is considered “normal” in the
oral cavity lies outside of the range of individual
variability. Accepting this de#nition, some of the
“mucogingival conditions and deformities” listed
previously (Table 1) such as lack of keratinized tissues,
decreased vestibular depth, aberrant frenum/muscle
position, are discussed since these are conditions not
necessarily associated with the development of
pathosis. Conversely, in individual cases they can be
associated with periodontal health. In fact, it is well-
documented and a common clinical observation that
periodontal health can be maintained despite the lack
of keratinized tissue, as well as in the presence of frena
and shallow vestibule when the patient applies
appropriate oral hygiene measures and professional
maintenance in the absence of other factors associated
with increased risk of development of gingival recession,
gingivitis, and periodontitis.2, 10 Thereby, what could
make the di"erence, for the need of professional
intervention, is patient behavior in terms of oral care
and the need for orthodontic, implant, and restorative
treatments.

CASE DEFINITIONS
Periodontal biotype
One way to describe individual di"erences as they
relate to the focus of this review is the “periodontal
:
 relate to the focus of this review is the “periodontal
biotype”. The “biotype” has been labeled by di"erent
authors as “gingival” or “periodontal” “biotype”,
“morphotype” or “phenotype”. In this review, it will be
referred to as periodontal biotype. The assessment of
periodontal biotype is considered relevant for outcome
assessment of therapy in several dental disciplines,
including periodontal and implant therapy,
prosthodontics, and orthodontics. Overall, the
distinction among di"erent biotypes is based upon
anatomic characteristics of components of the
masticatory complex, including 1) gingival biotype,
which includes in its de#nition gingival thickness (GT)
and keratinized tissue width (KTW); 2) bone morphotype
(BM); and 3) tooth dimension.

A recent systematic review using the parameters

reported previously, classi#ed the “biotypes” in three
categories:11
Thin scalloped biotype in which there is a greater
association with slender triangular crown, subtle
cervical convexity, interproximal contacts close to the
incisal edge and a narrow zone of KT, clear thin
delicate gingiva, and a relatively thin alveolar bone.

Thick !at biotype showing more square-shaped tooth

crowns, pronounced cervical convexity, large
interproximal contact located more apically, a broad
zone of KT, thick, #brotic gingiva, and a comparatively
thick alveolar bone.

Thick scalloped biotype showing a thick #brotic gingiva,

slender teeth, narrow zone of KT, and a pronounced
gingival scalloping.

The strongest association within the di"erent

parameters used to identify the di"erent biotypes is
found among GT, KTW, and BM. These parameters have
been reported to be frequently associated with the
:
 been reported to be frequently associated with the
development or progression of mucogingival defects,
recession in particular.

Keratinized tissue width ranges in a thin biotype from

2.75 (0.48) mm to 5.44 (0.88) mm and in a thick biotype
from 5.09 (1.00) mm to 6.65 (1.00) mm. The calculated
weighted mean for the thick biotype was 5.72 (0.95) mm
(95% CI 5.20; 6.24) and 4.15 (0.74) mm (95% CI 3.75;
4.55) for the thin biotype.

Gingival thickness ranges from 0.63 (0.11) mm to 1.79

(0.31) mm. An overall thinner GT was assessed around
the cuspid and ranged from 0.63 (0.11) mm to 1.24
(0.35) mm, with a weighted mean (thin) of 0.80 mm
(0.19). When discriminating between either thin or thick
periodontal biotype in general, a thinner GT can be
found in a thin biotype population regardless of the
selected study.

Bone morphotype resulted in a mean buccal bone

thickness of 0.343 (0.135) mm for thin biotype and 0.754
(0.128) mm for thick/average biotype. Bone morphotypes
have been radiographically measured with cone-beam
computed tomography (CBCT).12, 13

Tooth position

The in$uence of tooth position in the alveolar process is

important. The bucco-lingual position of teeth shows
increased variability in GT, i.e., buccal position of teeth is
frequently associated with thin gingiva14 and thin labial
bone plate.13

Prevalence of di"erent biotypes varies in studies that

consider di"erent parameters in this classi#cation. In
general, a thick biotype (51.9%) is more frequently
observed than a thin biotype (42.3%) when assessed on
:
 observed than a thin biotype (42.3%) when assessed on
the basis of gingival thickness, and distributed more
equally when assessed on the basis of gingival
morphotype (thick 38.4%, thin 30.3%, normal 45.7%).

It is generally stated that thin biotypes have a tendency

to develop more gingival recessions than do thick
ones.2, 10 This might in$uence the integrity of the
periodontium through the patient's life and constitute a
risk when applying orthodontic,15 implant,16 and
restorative treatments.17

Gingival thickness, is assessed by:

Transgingival probing (accuracy to the nearest 0.5
mm). This technique must be performed under local
anesthesia, which could induce a local volume
increase and possible patient discomfort.18

Ultrasonic measurement.19 This shows a high

reproducibility (within 0.5 to 0.6 mm range) but a
mean intra-individual measurement error is revealed
in second and third molar areas. A repeatability
coe%cient of 1.20 mm was calculated.20

Probe visibility21 after its placement in the facial

sulcus. Gingiva was de#ned as thin (≤1.0 mm) or thick
(>1 mm) upon the observation of the periodontal
probe visible through the gingiva. This method was
found to have a high reproducibility by De Rouck et
al,22 showing 85% inter-examiner repeatability (k
value = 0.7, P- value = 0.002). The authors scored GT
as thin, medium, or thick. Recently, a color-coded
probe was proposed to identify four gingival biotypes
(thin, medium, thick and very thick).23

Keratinized tissue width is easily measured with a

periodontal probe positioned between the gingival
margin and the mucogingival junction.

Although bone thickness assessment through CBCT has

:
 Although bone thickness assessment through CBCT has
high diagnostic accuracy12, 13, 24 the exposure to
radiation is a potentially harmful factor.

Gingival recession
Gingival recession is de#ned as the apical shift of the
gingival margin with respect to the cemento-enamel
junction (CEJ);1 it is associated with attachment loss and
with exposure of the root surface to the oral
environment. Although the etiology of gingival
recessions remains unclear, several predisposing
factors have been suggested.

Periodontal biotype and attached gingiva

A thin periodontal biotype, absence of attached gingiva,

and reduced thickness of the alveolar bone due to
abnormal tooth position in the arch are considered risk
factors for the development of gingival recession.2, 3,
11 The presence of attached gingival tissue is
considered important for maintenance of gingival
health. The current consensus, based on case series and
case reports (low level of evidence), is that about 2 mm
of KT and about 1 mm of attached gingiva are desirable
around teeth to maintain periodontal health, even
though a minimum amount of keratinized tissue is not
needed to prevent attachment loss when optimal
plaque control is present.2

The impact of toothbrushing

“Improper” toothbrushing method has been proposed

as the most important mechanical factor contributing to
the development of gingival recessions.3, 25-28 A recent
systematic review however, concluded that the “data to
support or refute the association between
toothbrushing and gingival recession are
inconclusive”.28, 29 Among the 18 examined studies,
:
 inconclusive”.28, 29 Among the 18 examined studies,
one concluded that the toothbrushes signi#cantly
reduced recessions on facial tooth surfaces over 18
months, two concluded that there appeared to be no
relationship between toothbrushing frequency and
gingival recession, while eight studies reported a
positive association between toothbrushing frequency
and recession. Several studies reported potential risk
factors like duration of toothbrushing, brushing force,
frequency of changing the toothbrush, brush (bristle)
hardness and tooth-brushing technique.

The impact of cervical restorative margins

A recent systematic review2 reported clinical

observations suggesting that sites with minimal or no
gingiva associated with intrasulcular restorative margins
are more prone to gingival recession and in$ammation.
The authors concluded that gingival augmentation is
indicated for sites with minimal or no gingiva that are
receiving intra-crevicular restorative margins. However,
these conclusions are based mainly on clinical
observations (low level of evidence).

The impact of orthodontics

There is a possibility of gingival recession initiation or

progression of recession during or after orthodontic
treatment depending on the direction of the
orthodontic movement.30, 31 Several authors have
demonstrated that gingival recession may develop
during or after orthodontic therapy.32-36 The reported
prevalence is spanning 5% to 12% at the end of
treatment. Authors report an increase of the prevalence
up to 47% in the long-term observation (5 years).
However, it has been demonstrated that, when a facially
positioned tooth is moved in a lingual direction within
the alveolar process, the apico-coronal tissue dimension
:
 the alveolar process, the apico-coronal tissue dimension
on its facial aspect will increase in width.37, 38 A recent
systematic review2 concluded that the direction of the
tooth movement and the bucco-lingual thickness of the
gingiva may play important roles in soft tissue alteration
during orthodontic treatment. There is a higher
probability of recession during tooth movement in
areas with <2 mm of gingiva. Gingival augmentation can
be indicated before the initiation of orthodontic
treatment in areas with <2 mm. These conclusions are
mainly based on historic clinical observations and
recommendations (low level of evidence).

Other conditions

There is a group of conditions, frequently reported by

clinicians that could contribute to the development of
gingival recessions (low level of evidence).39 These
include persistent gingival in$ammation (e.g. bleeding
on probing, swelling, edema, redness and/or
tenderness) despite appropriate therapeutic
interventions and association of the in$ammation with
shallow vestibular depth that restricts access for
e"ective oral hygiene, frenum position that
compromises e"ective oral hygiene and/or tissue
deformities (e.g. clefts or #ssures). Future studies and
documentation focusing on these conditions should be
done.

Diagnostic considerations

Proposed clinical elements for a treatment-oriented

recession classi#cation are as follows.

Recession depth

A recent meta-analysis concludes that the deeper the

recession, the lower the possibility for complete root
coverage.40 Since recession depth is measured with a
periodontal probe positioned between the CEJ and the
:
 periodontal probe positioned between the CEJ and the
gingival margin, it is clear that the detection of the CEJ is
key for this measurement. In addition, the CEJ is the
landmark for root coverage. In many instances,
however, CEJ is not detectable because of root caries
and / or non-carious cervical lesions (NCCL), or is
obscured by a cervical restoration. Modern dentistry
should consider the need for anatomical CEJ
reconstruction before root coverage surgery to re-
establish the proper landmark.41, 42

Gingival thickness

GT <1 mm is associated with reduced probability for

complete root coverage when applying advanced
$aps.43, 44 GT can be measured with di"erent
approaches, as reported previously. To date, a
reproducible, and easy approach is observing a
periodontal probe detectable through the soft tissues
after being inserted into the sulcus.21-23

Interdental clinical attachment level (CAL)

It is widely reported that recessions associated with

integrity of the interdental attachment have the
potential for complete root coverage, while loss of
interdental attachment reduces the potential for
complete root coverage and very severe interdental CAL
loss impairs that possibility; some studies, however,
report full root coverage in sites with limited interdental
attachment loss.45, 46

A modern recession classi#cation based on the

interdental CAL measurement has been proposed by
Cairo et al.47
Recession Type 1 (RT1): Gingival recession with no
loss of interproximal attachment. Interproximal CEJ is
clinically not detectable at both mesial and distal
aspects of the tooth.
:
 aspects of the tooth.

Recession Type 2 (RT2): Gingival recession

associated with loss of interproximal attachment. The
amount of interproximal attachment loss (measured
from the interproximal CEJ to the depth of the
interproximal sulcus/pocket) is less than or equal to
the buccal attachment loss (measured from the
buccal CEJ to the apical end of the buccal
sulcus/pocket).

Recession Type 3 (RT3): Gingival recession

associated with loss of interproximal attachment. The
amount of interproximal attachment loss (measured
from the interproximal CEJ to the apical end of the
sulcus/pocket) is greater than the buccal attachment
loss (measured from the buccal CEJ to the apical end
of the buccal sulcus/pocket).

This classi#cation overcomes some limitations of the

widely used Miller classi#cation48 such as the di%cult
identi#cation between Class I and II, and the use of
“bone or soft tissue loss” as interdental reference to
diagnose a periodontal destruction in the interdental
area.49 In addition, Miller classi#cation was proposed
when root coverage techniques were at their dawn and
the forecast of potential root coverage in the four Miller
classes is no longer matching the treatment outcomes
of the most advanced surgical techniques.49

The Cairo classi#cation is a treatment-oriented

classi#cation to forecast the potential for root coverage
through the assessment of interdental CAL. In the Cairo
RT1 (Miller Class I and II) 100% root coverage can be
predicted; in the Cairo RT2 (overlapping the Miller class
III) some randomized clinical trials indicate the limit of
interdental CAL loss within which 100% root coverage is
predictable applying di"erent root coverage
procedures; in the Cairo RT3 (overlapping the Miller
:
 procedures; in the Cairo RT3 (overlapping the Miller
class IV) full root coverage is not achievable.46, 47

Clinical conditions associated with gingival recessions

The occurrence of gingival recession is associated with

several clinical problems that introduce a challenge as
to whether or not to choose surgical intervention. A
basic question to be answered is: what occurs if an
existing gingival recession is left untreated? A recent meta-
analysis assessed the long-term outcomes of untreated
facial gingival recession defects.50 The authors
concluded that untreated facial gingival recession in
subjects with good oral hygiene is highly likely to result
in an increase in the recession depth during long-term
follow-up. Limited evidence, however, suggests that the
presence of KT and/or greater gingival thickness
decrease the likelihood of a recession depth increase or
of development of new gingival recession.

Agudio et al.51 (2016) compared the periodontal

conditions of gingival augmentation sites versus
untreated homologous contralateral sites presenting
with thin gingival biotype with or without recessions in a
population of highly motivated patients. At the end of
the follow-up period (mean of 23.6 ± 3.9 years, range 18
to 35 years), the extent of the recession was reduced in
83% of the 64 treated sites, whereas it was increased in
48% of the 64 untreated sites. However, the amount of
recession increase in 20 years was very limited: 1 mm in
24 units, 2 mm in 6 and 3 mm in one. This study showed
that thin gingival biotypes augmented by grafting
procedures remain more stable over time than do thin
gingival biotypes; however, highly motivated patients
can prevent the development / progression of gingival
recession and in$ammation for more than 20 years.
Limited evidence also suggests that existing or
:
 Limited evidence also suggests that existing or
progressing gingival recession does not lead to tooth
loss.50, 51 Even though progression of gingival
recession seems not to impair the long-term survival of
teeth it may be associated with problems like esthetic
impairment, dentin hypersensitivity, and tooth
conditions that concern the patient and the clinician.

Esthetics

Smile esthetics is becoming a dominant concern for

patients, in particular when dental treatment is
required. However, most of the articles that have been
published on this topic did not consider patient-
reported outcomes.2, 52 A recent survey of the
American Academy of Cosmetic Dentistry (2013)
consisting of 659 interviews reported that 89% of the
patients decided to start cosmetic dental treatment in
order to improve physical attractiveness and self-
esteem. Several factors are important in the esthetics of
the smile, including the facial midline, the smile line,
interdental papillary recession, the size, shape, position,
and color of the teeth, the gingival sca"old, and the lip
framework.53-59 All of these factors contribute to the
esthetics of a smile. In particular, factors associated with
the gingival sca"old are the position of the free gingival
margins, the color/texture of the gingiva, the presence
of scars, and the amount of gingiva displayed by the
smile.53, 54, 56-58 However, even if all of these factors
are identi#ed by the clinicians, little information is
available about which variables are better perceived by
the patients.60 It is very clear that esthetic ratings are
based on subjective assessment. In a recent study
patients' perception of facial recessions and their
requests for treatment were evaluated by means of a
questionnaire.61 Of 120 enrolled patients, 96 presented
783 gingival recessions, of which 565 had been
unperceived. Of 218 perceived recessions, 160 were
:
 unperceived. Of 218 perceived recessions, 160 were
asymptomatic, 36 showed dental hypersensitivity, 13
esthetic issues, and nine esthetic + hypersensitivity
issues. Only 11 patients requested treatment for their
57 recessions. The authors concluded that perception of
gingival recessions and the patients' requests for
treatment should be evaluated carefully before
proceeding to treatment. Interestingly, a survey among
dentists showed that esthetics account for 90.7% of the
justi#cation for root coverage procedures.62 Recently,
the Smile Esthetic Index (SEI) has been proposed and
validated.63 Ten variables were chosen as determinants
for the esthetics of a smile: smile line and facial midline,
tooth alignment, tooth deformity, tooth dyschromia,
gingival dyschromia, gingival recession, gingival excess,
gingival scars, and diastema/missing papillae. The
presence/absence of the aforementioned variables
correspond to a number (0 or 1), and the sum of the
attributed numbers represent the SEI of that subject
(from 0 – very bad, to 10 – very good). The SEI was
found to be a reproducible method to assess the
esthetic component of the smile, useful for the
diagnostic phase and for setting appropriate treatment
plans.

Dentin hypersensitivity

Dentin hypersensitivity (DH) is a common, often

transient oral pain condition. The pain, short and sharp,
resulting immediately on stimulation of exposed dentin
and resolving on stimulus removal, can a"ect quality of
life.64, 65 Of a study population of 3,000 patients, 28%
stated that DH a"ected them importantly or very
importantly.66 Prevalence #gures range widely from
15% to 74% depending on how the data were collected.
Risk factors include gingival recession. Furthermore, an
erosive diet and lifestyle are linked to tooth wear and
:
 erosive diet and lifestyle are linked to tooth wear and
dentin hypersensitivity, especially in young adults.66
Because life expectancy is rising and people are
retaining more vital or minimally restored teeth,67
dentin hypersensitivity occurs more frequently.
Treatment modalities include the use of di"erent agents
applied to the root surfaces68 or the application of root
coverage procedures.69 In a recent systematic
review,69 the authors analyzed nine studies on the
in$uence of root coverage procedures on cervical DH. A
reduction in Cervical DH was reported in all studies
reviewed. The mean percentage of decreased DH was
77.83%. The authors concluded that these results must
be viewed with caution because most of the studies had
a high risk of bias and cervical DH was assessed as a
secondary outcome. There is not enough evidence to
conclude that surgical root coverage procedures
predictably reduce cervical DH.

Tooth conditions

Di"erent conditions of the tooth, including root caries67

and non-carious cervical lesions (NCCL)70, 71 may be
associated with a gingival recession. Historically, NCCL
have been classi#ed according to their appearance:
wedge-shaped, disc-shaped, $attened and irregular
areas.70, 71 A link between the morphological
characteristics of the lesions and the main etiological
factors is suspected. Thus, a U-shaped or disk-shaped
broad and shallow lesion, with poorly de#ned margins
and adjacent smooth enamel suggests an extrinsic
erosive cause by acidic foods, beverages, and
medication. Lesions caused by abrasive forces, such as
improper toothbrushing techniques, generally exhibit
sharply de#ned margins and on examination reveal
hard surface traces of scratching. There is no
scienti#cally sound evidence that abnormal occlusal
:
 scienti#cally sound evidence that abnormal occlusal
loading causes non-carious cervical lesions
(abfraction).9 However, the shape cannot be considered
determinative of the etiology. Recent studies found a
prevalence of NCCL ranging from 11.4% to 62.2%. A
common #nding is that prevalence and severity of NCCL
appears to increase with age.70-72

The presence of these dental lesions causes

modi#cations of the root/tooth surface with a potential
disappearance of the original CEJ and/or the formation
of concavities (steps) of di"erent depth and extension
on the root surface. Pini-Prato et al.73 (2010) classi#ed
the presence/absence of CEJ as Class A (detectable CEJ)
or Class B (undetectable CEJ), and the presence/absence
of cervical concavities (step) on the root surface as Class
+ (presence of a cervical step >0.5 mm) or Class –
(absence of cervical step). Therefore, a classi#cation
includes four di"erent scenarios of tooth-related
conditions associated with gingival recessions. (Table 2).

Table 2. Classi#cation system of four di"erent classes of

root surface concavities

CEJ Step Descriptors

Class A - CEJ detectable without step

Class A + CEJ detectable with step

Class B - CEJ undetectable without step

Class B + CEJ undetectable with step

The prevalence of tooth deformities associated with

gingival recessions is very high. In the cited study73
more than half of the 1,010 screened gingival recessions
:
 more than half of the 1,010 screened gingival recessions
were associated with tooth deformities: 469 showed an
identi#able CEJ without a step on the root surface (Class
A-, 46%); 144 an identi#able CEJ associated with a step
(Class A+, 14%); 244 an unidenti#able CEJ with a step
(Class B+, 24%); and 153 an unidenti#able CEJ without
any associated step (Class B-, 15%). The presence of
NCCL is associated with a reduced probability for
complete root coverage.74, 75

DIAGNOSTIC AND TREATMENT

CONSIDERATIONS BASED ON
CLASSIFICATION OF
PERIODONTAL BIOTYPES,
GINGIVAL RECESSION, AND
ROOT SURFACE CONDITIONS
On the basis of the various aspects discussed in the
present review a diagnostic approach of the dento-
gingival unit is proposed to classify gingival recessions
and the associated relevant mucogingival conditions
and cervical lesions with a treatment-oriented vision
(Table 3). The proposed diagnostic table is based on a 4
× 5 matrix and is explained through the following cases
a to d.

1. Absence of gingival recessions

The classi#cation is based on the assessment of

the gingival biotype, measured through GT and
KTW, either in the full oral cavity or in single sites
(Table 3).
Case a. Thick gingival biotype without gingival
recession: prevention through good oral hygiene
instruction and monitoring of the case.
Case b. Thin gingival biotype without gingival
:
 Case b. Thin gingival biotype without gingival
recession: this entails a greater risk for future
development of gingival recessions. Attention of
the clinicians to prevention and careful monitoring
should be enhanced. With respect to cases with
severe thin gingival biotype application of
mucogingival surgery in high-risk sites could be
considered to prevent future mucogingival
damage. This applies especially in cases in which
additional treatment like orthodontics, restorative
dentistry with intrasulcular margins, and implant
therapy are planned.

2. Presence of gingival recessions

A treatment-oriented classi#cation could be based

on the interdental clinical attachment level (score
Cairo RT1-3) and enriched with the quali#ers
recession depth, gingival thickness, keratinized tissue
width, and root surface condition. Other potential
contributors are tooth position, cervical tooth wear
and number of adjacent recessions.
Case c. A conservative clinical attitude should
employ charting the periodontal and root surface
lesions and monitoring them overtime for
deterioration. The distance from the CEJ to FGM
should be recorded as well as the distance
between MGJ and FGM to determine the amount
of KT present. Development and increased severity
of both periodontal and dental lesions would
orient clinicians toward appropriate treatment
(see Case d).
Case d. A treatment-oriented approach, especially
in thin biotypes and when justi#ed by patient
concern or complaint in terms of esthetics and/or
dentin hypersensitivity and by the presence of
cervical caries or NCCL, should consider
:
 cervical caries or NCCL, should consider
mucogingival surgery for root coverage and CEJ
reconstruction when needed. This applies
especially to cases in which additional treatment
like orthodontics, restorative dentistry with
intrasulcular margins, and implant therapy are
planned.

Table 3. Classi#cation of gingival biotype and gingival

recession

RT = recession type, REC Depth = depth of the gingival recession, GT=

gingival thickness, KTW= keratinized tissue width, CEJ = cement

enamel junction (Class A = detectable CEJ. Class B = undetectable CEJ),

Step = root surface concavity (Class + = presence of a cervical step

>0.5 mm. Class – = absence of cervical step).

Recent information on the best approaches to prevent

the occurrence of gingival recessions or to treat single
or multiple recessions can be found in reviews and
reports from the 2014 European Federation of
Periodontology (EFP) and 2015 American Academy of
Periodontology (AAP) workshops.2, 8, 45, 46, 76, 77

The clinical impact and the prevalence of the root

surface lesion, hypersensitivity and patient aesthetic
concern associated to gingival recessions indicates the
need to modify the 1999 classi#cation on mucogingival
deformities and conditions.

The new classi#cation includes additional information,

such as periodontal biotype, recession severity,
dimension of the residual gingiva, presence/absence of
:
 dimension of the residual gingiva, presence/absence of
caries and non-carious cervical lesions, aesthetic
concern of the patient, and presence of dentin
hypersensitivity (Figure 1).

*Figure Open in !gure viewer  PowerPoint

1

Modi#ed from the AAP 1999 Consensus Report, shown in

Table 1.

SUMMARY AND CONCLUSIONS

Periodontal health can be maintained in most patients
under optimal oral conditions even with minimal
amounts of keratinized tissue. However, there is an
increased risk of development or progression of gingival
recession in cases presenting with thin periodontal
biotypes, suboptimal oral hygiene, and requiring
restorative/ orthodontic treatment.
Development and progression of gingival recession is
not associated with increased tooth mortality. It is,
however, causing esthetic concern in many patients
and is frequently associated with the occurrence of
dentin hypersensitivity and carious/non-carious
cervical lesions on the exposed root surface.

Esthetic concern, dentin hypersensitivity, cervical

lesions, thin gingival biotypes and mucogingival
deformities are best addressed by mucogingival
surgical intervention when deemed necessary.

A novel treatment-oriented classi#cation based on

the assessment of gingival biotype, gingival recession
severity and associated cervical lesions is proposed
to help the clinical decision process.
:
 to help the clinical decision process.

ACKNOWLEDGMENTS AND
DISCLOSURES
The authors report no con$icts of interest related to this
case de#nition paper.

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