In health, there are two types of gum tissues (gingiva)
that surround the tooth. The part that is around the neck of the tooth is
firmly attached to the tooth and underlying bone, and is called
attached gingiva. The attached gingiva is
immovable and tough, and is resistant to normal trauma form eating, tooth
brushing etc. Right below the attached gingiva a looser gum tissue
called alveolar mucosa. This tissue is loose to allow the movement of the
lip and the cheeks, but is not tough enough to withstand the normal trauma
form eating and tooth brushing.
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Adequate attached (hard) gum to prevent
spontaneous recession. No grafting needed. |
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| Genetically each one
of us has different width and thickness of attached gingiva. Some
people are born with thin or insufficient attached gingiva. In
these cases the gum slowly continues to recede over time, even though the
patient may be very conscientious with their oral health. This is not an
infection, as is seen with periodontal disease, but rather simply an
anatomic condition. Unfortunately, bone recession is occurring at the same
time the gum is receding. This is because the bone, which is just under the
gum, will not allow itself to become exposed to the oral cavity and moves
down with the gum. |
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Insufficient attached gum
results in recession starting |
Insufficient attached gum
without treament results in
continued loss of gum and bone |
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Lack of attached gum with resulting recession |
Note gum pulling away when cheek muscle retracted. The bone that
previously covered the root has also receded. |
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| A lack of attached
gingiva is sometimes associated with a high frenum
attachment, which exaggerates the pull on the gum margin. A frenum is a
naturally occurring muscle attachment, normally seen between the front teeth
(either upper or lower). It is normal to have a frenum, but it should not
pull on the gum margin or recession will occur. If pulling is seen, the
frenum is surgically released from the gum with a
frenectomy. Often a new band of hard gum is also added to
re-establish an adequate amount of attached gingiva (see below). |
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Child with naturally
occuring
high frenum attachment |
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| High frenum with lack
of attached gum causing muscle pull and tooth separation |
After frenum removal,
and
addition of adequate attached gingiva |
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| With the wear and tear
of time, even normal attached gum can be worn away, generally from vigorous
brushing. This often happens in people with naturally thin tissues, or when
the tissues have been stretched during orthodontics. If there is still
adequate attached gum to act as a barrier to the muscle, the treatment for
recession is to ensure further damage isn't done when brushing. However, if
the attached gum is worn to the point where it cannot resist the constant
pull of the mucosa, recession will continue unless a new hard band of gum is
placed. Unchecked, the recession can cause tooth loss as the bone recedes
with the tissue and tooth support weakens. |
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| Recession associated with a lack of
attached gingiva. The bone has also receded. Untreated, this may result
in tooth loss. |
After placement of a gum graft, adequate
attached gingiva to prevent further bone/tissue loss. |
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| Recession with no attached gum. Without
treatment, the recession will continue. The root is difficult to clean,
leading to plaque formation and inflammation. |
After placement of new
attached gum. |
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| The replacement of
missing attached gum is called gingival grafting.
The muscle that is pulling down on the edge of the gum is first surgically
resected and repositioned away from the gum margin. Then a small piece of
attached gingiva is taken from the roof of the mouth, just adjacent to the
back teeth, and transplanted to the site in question. The new tissue
reattaches and reforms a new layer of attached gum, which should last a
lifetime with proper care. The roof of the mouth heals quickly, just like a
skinned knee might. With this procedure the root is not covered, and the
tissue stays at the same level as before, except with attached gingiva at
the margin. These procedures are very easy on the patient, and rarely
require more than over-the-counter pain pills post-operatively (ibuprofen).
The most difficult part of the surgery is not chewing on the area for 2
weeks. (See
Free Gingival Graft-Clinical Case)
Routine gum grafts ("free gingival grafts") do not cover up the exposed
root surface - if this is desired, a different technique is used (See
Cosmetic Procedures, Root Coverage). Covering the root does not make the
tooth stronger, for the bone, which actually holds the tooth in place, does
not change regardless of the new gum level. Rather, root coverage procedures
are primarily done for cosmetic reasons, or when there is exceptional root
sensitivity after recession. |
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| Recession with a lack of attached gingiva.
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Gum graft placed, resulting in
adequate attached gingiva and health. The root is not covered. |
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