Assessment of Effect of Orthodontic Treatment on the Stability of Pre-Orthodontic Recession Coverage by Connective Tissue Graft. A Randomized Controlled Clinical Trial

Gingival recession is the location of the gingival margin apical to the cemento-enamel junction. The consequences of gingival recession range from impairment of esthetics, development of dentin hypersensitivity, root caries and an especially high incidence of non-carious cervical lesions.

The etiology of gingival recession is held to be multifactorial with various predisposing and precipitating factors recognized. The most commonly implicated risk factors include bone dehiscence/fenestration, tooth malposition (especially facially positioned teeth), thin gingival phenotype, the narrow width of keratinized gingiva, frenum pull, the presence of gingival inflammation, overzealous toothbrushing, and faulty dental restorations. Apart from these, certain types of orthodontic tooth movements are also assumed to precipitate gingival recession although conclusive evidence in support of this postulation is still needed and if indeed true, the precise underlying mechanism still unclear.

Most of the studies have focused on the contribution of orthodontic treatment induced incisor proclination (outside the dentoalveolar envelope) as a causative factor for the development of gingival recession and the findings have been indecisive. While some studies support this premise, others have observed no such correlation. Correspondingly, the issue of periodontal intervention in order to prevent development and/or progression of gingival recession in patients scheduled for orthodontic treatment remains unclear. One approach supports performing gingival augmentation prior to initiation of orthodontic tooth movement. The basis for this approach rests in the concept of the importance of the minimum amount of attached gingiva needed for dissipating forces of muscle pull, unattached mucosa and masticatory stresses and facilitation of patient performed oral hygiene procedures. Esthetic improvement, management of dentinal hypersensitivity and prevention of root caries are other expected benefits specifically associated with performing root coverage surgery. Moreover, improvement of gingival tissue dimensions before orthodontic tooth movement is expected to prevent further deterioration of preexisting gingival recession and better withstand orthodontic forces. Therefore, this approach is typically a preventive one. However, supporters of the other perspective, i.e. waiting for gingival augmentation surgery until after orthodontic treatment is over believe that it is best to wait until the gingival recession develops into a pathological entity and becomes a real clinical problem warranting corrective treatment. In fact, they regard the aforementioned preventive approach as a sort of 'overtreatment' and therefore avoidable. There are also concerns expressed regarding the long-term stability of gingival marginal levels achieved with mucogingival surgery performed before orthodontic tooth movement. Based on the above discussion, it is apparent that there is wide subjectivity regarding clinical decision making in cases where orthodontic treatment is planned in patients displaying gingival recession. Currently, both the indications as well as the timing of carrying out root coverage procedures in patients scheduled for orthodontic treatment are not very well elaborated. A thorough search of the literature revealed a very modest level of evidence - one study with prospective and retrospective data collection and the other a retrospective study. In both the studies, gingival augmentation surgery was carried out before the orthodontic intervention. Therefore, a need is felt for conducting a well-designed research in order to dissipate the conflict of opinions existing over this vital clinical issue. The high prevalence of gingival recession among patients needing orthodontic treatment renders this question even more vital. The current study has thus been conceived and designed so as to help resolve this clinical decision making conundrum. In the proposed study, a comparative evaluation of clinical and radiographic parameters pre and post-orthodontic treatment in teeth with gingival recession between participants undergoing gingival recession coverage before the initiation of orthodontic tooth movement with participants not undergoing pre-orthodontic root coverage will be done. The root coverage procedure chosen is sub-epithelial connective tissue graft since it is recognized as the gold standard among all recession coverage surgical procedures.

The present prospective, analytical, randomized controlled clinical trial will be conducted in the Department of Periodontics and Oral Implantology in collaboration with Department of Orthodontics, Post Graduate Institute of Dental Sciences, Rohtak.

Systemically healthy individuals having slight crowding in the anterior region, with at least one tooth having a gingival recession in the same region.