Options for Altering Tissue Position

The need to alter the position of the gingival tissue is something we all commonly face as restorative dentists. We regularly see patients with recession on their natural teeth, as well as those who present with recession on teeth that have been restored.

As clinicians, it's up to us to offer conservative solutions that address both the esthetic and biologic needs of each individual patient. When it comes to managing patients with recession, there are generally two options that can be used to successfully reposition the tissue in a more coronal position.

Connective tissue root coverage: As can be seen in this photo, recession can result in extremely long, un-esthetic teeth. The use of connective tissue (either an autograft (the patient's own soft tissue) or an allograft (donor tissue) to surgically correct areas of recession is well documented in the literature. Areas of recession that have previously been restored with composite (as is seen on the canines) can make the process of root coverage more difficult, but not impossible.

In this situation, removing the material and plastying the root can create a nice recipient area for the graft material. If the restorative material is not removed, then the expectation of obtaining any soft tissue coverage is extremely low. In this situation, allograft material was used to cover correct the recession followed by the placement of restorations.

Orthodontic eruption: Another option to move the gingival margin coronally is to use orthodontics. The goal with this treatment option is to orthodontically erupt the teeth with recession, thereby moving the bone and soft tissue more coronally. Looking at the second patient, you'll notice that the left lateral incisor had significant recession, but was restored to the level of the gingival margin thereby removing connective tissue root coverage as a treatment option to correct its position.

It's important to point out that the recession on this lateral is most likely present because the tooth is in a more facial position. If there is a facial dehiscence or fenestration present on this tooth, the bone and gingiva may not follow when the tooth is the orthodontically erupted. If the tooth was to be orthodontically erupted and the tissue did not move coronal as was desired, a soft tissue root coverage procedure can be done "after" the orthodontics to cover the root surface in any area where root structure becomes exposed. In this example, orthodontics was used to erupt both the lateral and central to help correct the gingival margin locations, followed by replacement with a new 3-unit FPD.