**Amelia Hemmati** **GINGIVAL** **RECESSION** **GINGIVAL** **OVERGROWTH** Amelia Hemmati #### Presentation Overview - Gingival Recession - Gingival Overgrowth **Key References** All images are from the above references as well as from Periodontics: The Complete Summary (2021) and Periodontal Review Q&A (2020) #### Key References All images are sourced from the primary references, as well as the following supplemental texts: - Periodontics: The Complete Summary (2021) - Periodontal Review Q&A (2020) # Contents ## Gingival Recession * Definition * Epidemiology * Aetiology * Classification * Clinical Consequences * Indications for Treatment * Management * Prognostic Factors * Evidence-Based Perspective ## Gingival Enlargement * Classification * Pathogenesis of Drug-Induced Overgrowth * Clinical Features * Complications * Management * Recurrence #### Gingival Recession - Definition - Epidemiology - Aetiology - Classification - Clinical Consequences - Indications for Treatment - Management - Prognostic Factors - Evidence-Based Perspective #### Gingival Enlargement - Classification - Pathogenesis of Drug-Induced Overgrowth - Clinical Features - Complications - Management - Recurrence Part 1 - Gingival Recession Part 1 - Gingival Recession **Definition** Gingival recession is the apical displacement of the gingival margin relative to the cemento-enamel junction (CEJ), resulting in root surface exposure.  #### Definition Gingival recession is the apical displacement of the gingival margin relative to the cemento-enamel junction (CEJ), resulting in root surface exposure. Clinical photos demonstrating gingival recession. The images show the apical displacement of the gingival margin relative to the cemento-enamel junction (CEJ), resulting in visible root surface exposure on the teeth. - *Epidemiology* - Increases with age - Common in patients with history of periodontitis - Frequently seen in patients with high traumatic toothbrushing habits - Highly prevalent in thin periodontal phenotypes   #### Epidemiology - Increases with age - Common in patients with history of periodontitis - Frequently seen in patients with high traumatic toothbrushing habits - Highly prevalent in thin periodontal phenotypes Clinical photo labeled 'Fig 6-10 Thin periodontal phenotype' showing a close-up of anterior teeth with a black probe measuring gingival thickness. The image demonstrates the thinness of the soft tissue attached to the tooth surface. Clinical photo labeled 'Fig 6-11 Thick periodontal phenotype' showing a close-up of anterior teeth with a black probe measuring gingival thickness. The image demonstrates a thicker band of pink soft tissue compared to Fig 6-10. **Aetiology** **Anatomical Factors** * Thin periodontal phenotype * **Dehiscence** and **fenestration** * Prominent roots * High **frenum** attachment ****   #### Anatomical Factors - Thin periodontal phenotype - Dehiscence and fenestration - Prominent roots - High frenum attachment Clinical photograph set labeled 'FIG. 65.2 High frenum attachments' showing four panels (A-D). Panel A shows a frenum between maxillary central incisors; B shows a frenum attached to the facial surface of maxillary lateral incisors; C shows a frenum on a mandibular incisor with orthodontic brackets; D shows a frenum on an incisor. The images demonstrate anatomical factors contributing to periodontal issues as listed in the text. Cross-sectional diagram labeled 'Figure 1.6 Bony fenestration and dehiscence'. Shows two tooth roots embedded in bone tissue. Labels point to 'Fenestration' (a hole in the bone surrounding the root) and 'dehiscence' (bone loss at the crest of the alveolar ridge next to the root). Caption explains these areas may be covered by soft tissue but can lead to gingival recession if associated with soft tissue loss. **Aetiology** Inflammatory Factors * Plaque-induced gingival inflammation * History of periodontitis <style scoped="true">{table:first-child th:nth-child(1), table:first-child td:nth-child(1) { background-color: black; }</style> <style scoped=""> </style> **Figure 8.6** Clinical plaque-induced gingivitis. There is visible plaque, blunted interdental papillae, and the marginal gingiva are red, slightly swollen and inflamed. **Figure 8.9** Patient with moderate chronic periodontitis showing swollen, inflamed gingivae and recession/clinical attachment loss. The gingival margins are blunted and there is loss of contour.   #### Inflammatory Factors - Plaque-induced gingival inflammation - History of periodontitis **Clinical Observations** - **Plaque-induced gingivitis:** Visible plaque, blunted interdental papillae, and red, slightly swollen, inflamed marginal gingiva. - **Chronic periodontitis:** Swollen, inflamed gingivae with recession/clinical attachment loss, blunted gingival margins, and loss of contour. Clinical photo: Figure 8.6 showing plaque-induced gingivitis. Visible plaque accumulation, blunted interdental papillae, and red, slightly swollen marginal gingiva indicating inflammation. Clinical photo: Figure 8.9 showing moderate chronic periodontitis. Swollen, inflamed gingivae with recession/clinical attachment loss; blunted gingival margins and loss of contour are evident. # Aetiology ## Traumatic Factors * Aggressive toothbrushing * Abrasive dentifrices * Oral piercings  ##### Traumatic Factors - Aggressive toothbrushing - Abrasive dentifrices - Oral piercings Clinical photo of the anterior lower dentition showing gingival recession and exposed root surfaces on multiple teeth. A metal oral piercing is visible in the lower lip mucosa. # Aetiology ## Iatrogenic Factors * Orthodontic tooth movement beyond alveolar envelope * Subgingival restorative margins * Poorly designed RPD clasps    ##### Iatrogenic Factors - Orthodontic tooth movement beyond alveolar envelope - Subgingival restorative margins - Poorly designed RPD clasps Clinical photos demonstrating subgingival restorative margins and gingival recession. The left panel shows a close-up of a tooth with the gum margin receded below the restoration edge. The right panel displays two adjacent teeth where the dark-colored crown margin is located beneath the gum tissue, illustrating the risk factor mentioned in the text. Clinical photo showing orthodontic treatment involving metal brackets and wires on upper teeth. The gums appear inflamed and red, potentially indicating issues related to orthodontic tooth movement beyond the alveolar envelope as described in the context. Clinical photo showing orthodontic appliances with a dental probe being used to measure or inspect the periodontal tissues. This demonstrates the clinical examination of potential complications from orthodontic tooth movement or poorly designed RPD clasps. **Classification** Miller Classification (1985) * Class I–IV based on **interdental tissue loss** **Fig 11-4 Miller's classification of soft tissue recession.** **Class 1** The marginal tissue recession does not extend to the mucogingival junction. There is no loss of interdental bone or soft tissue. **Class 2** The marginal tissue recession extends to the mucogingival junction. There is no loss of interdental bone or soft tissue. **Class 3** Recession extends to or beyond the mucogingival junction, with some periodontal attachment loss in the interdental area. **Class 4** Recession extends to or beyond the mucogingival junction, with severe bone and/ or soft tissue loss in the interdental area.   The Miller Classification (1985) categorizes recession into four classes based on interdental tissue loss: - **Class 1:** Marginal tissue recession does not extend to the mucogingival junction. No loss of interdental bone or soft tissue. - **Class 2:** Marginal tissue recession extends to the mucogingival junction. No loss of interdental bone or soft tissue. - **Class 3:** Recession extends to or beyond the mucogingival junction, with some periodontal attachment loss in the interdental area. - **Class 4:** Recession extends to or beyond the mucogingival junction, with severe bone and/or soft tissue loss in the interdental area. Table titled 'TABLE 22-1 Classification proposed by Miller in 1985'. The table has four columns: Class, Depiction (showing diagrams of teeth and gum recession for Classes I through IV), and Description. It details the criteria for each class based on recession extent relative to the mucogingival junction (MGJ) and interdental tissue loss. Labeled diagram illustrating Miller's classification of soft tissue recession (Fig 11-4). It consists of four horizontal rows corresponding to Class 1 through Class 4. Each row features a green arrow pointing to a text box describing the specific condition of that class regarding marginal tissue recession and interdental bone/soft tissue loss. # Classification Sullivan and Atkins (1968) Deep-wide Shallow-wide Deep-narrow Shallow-narrow Fig 22-2 Classification proposed by Sullivan and Atkins^22^ in 1968. Deep-wide Shallow-wide Deep-narrow Shallow-narrow The deep-wide defect is the most difficult area to treat. The graft should cover at least 5 mm of the connective tissue bed. Expect 1 to 2 mm of coverage. Expect 1 to 2 mm of new tissue over the apical portion. Rarely seen; expect complete coverage. Maintain by conservative therapy. Fig 11-5 Sullivan and Atkins classification.26   The Sullivan and Atkins (1968) classification categorizes defects by depth and width: 1. **Deep-wide:** The most difficult area to treat. The graft should cover at least 5 mm of the connective tissue bed. Expect 1 to 2 mm of coverage. 2. **Shallow-wide:** Expect 1 to 2 mm of new tissue over the apical portion. 3. **Deep-narrow:** Rarely seen; expect complete coverage. 4. **Shallow-narrow:** Maintain by conservative therapy. Labeled diagram (Fig 22-2) illustrating the Sullivan and Atkins (1968) classification of gingival defects. It displays four schematic cross-sections: 'Deep-wide' showing a wide pocket extending apically; 'Shallow-wide' with a broad but shallow recession; 'Deep-narrow' indicating a deep vertical defect; and 'Shallow-narrow' depicting a small localized defect. Clinical photograph composite (Fig 11-5) demonstrating the four Sullivan and Atkins classifications in actual patients. The image is divided into four panels labeled 'Deep-wide', 'Shallow-wide', 'Deep-narrow', and 'Shallow-narrow'. Below each photo is a text box describing treatment expectations: Deep-wide requires grafting at least 5mm of connective tissue bed; Shallow-wide expects 1-2mm new tissue over apical portion; Deep-narrow is rarely seen with complete coverage expected; Shallow-narrow should be maintained by conservative therapy. **Classification** **Cairo** Classification (2011) Developed following the 2017 World Workshop by the American Academy of Periodontology and European Federation of Periodontology - **RT1**: No interproximal attachment loss - **RT2**: Interproximal loss ≤ buccal loss - **RT3**: Interproximal loss > buccal loss (Cairo classification is now preferred.) <table> <caption>TABLE 22-2 Classification proposed by Cairo et al14 in 2011</caption> <thead> <tr> <th style="text-align:left">Class</th> <th style="text-align:left">Depiction</th> <th style="text-align:left">Description</th> </tr> </thead> <tbody> <tr> <td style="text-align:left">RT1</td> <td style="text-align:left"></td> <td style="text-align:left">• No interproximal attachment loss · Not detectible interproximal CEJ</td> </tr> <tr> <td style="text-align:left">RT2</td> <td style="text-align:left"></td> <td style="text-align:left">• Loss of interproximal attachment · Interproximal attachment loss ≤ buccal attachment loss</td> </tr> <tr> <td style="text-align:left">RT3</td> <td style="text-align:left"></td> <td style="text-align:left">• Loss of interproximal attachment · Interproximal attachment loss > buccal attachment loss</td> </tr> </tbody> </table> *RT: recession type; CEJ: cemento-enamel junction.*   Developed following the 2017 World Workshop, the Cairo classification is now the preferred system: - **RT1:** No interproximal attachment loss; interproximal CEJ is not detectable. - **RT2:** Loss of interproximal attachment where interproximal loss is less than or equal to buccal attachment loss. - **RT3:** Loss of interproximal attachment where interproximal loss is greater than buccal attachment loss. Clinical photograph labeled 'Fig 11-3 Staging' showing three panels (a, b, c) of gingival recession. Panel RT1 shows healthy tissue with no recession. Panel RT2 demonstrates recession where interproximal loss is less than or equal to buccal loss. Panel RT3 highlights severe recession in the anterior region where interproximal loss exceeds buccal loss. Table titled 'TABLE 22-2 Classification proposed by Cairo et al in 2011'. The table categorizes recession types into RT1, RT2, and RT3. Each row includes a visual diagram depicting the anatomical difference between interproximal and buccal attachment levels, alongside text descriptions defining the severity based on the comparison of these two measurements. # Clinical Consequences * Root sensitivity * Root caries * Non-carious cervical lesions * Aesthetic concerns * Plaque retention * Cervical abrasion     #### Clinical Consequences - Root sensitivity - Root caries - Non-carious cervical lesions - Aesthetic concerns - Plaque retention - Cervical abrasion Clinical photo showing multiple teeth with visible gingival recession and exposed root surfaces. The images illustrate conditions such as non-carious cervical lesions, aesthetic concerns, and potential plaque retention areas near the gumline. Clinical photo of anterior teeth exhibiting severe gingival recession and non-carious cervical lesions. The image highlights aesthetic concerns and possible plaque retention zones at the cervical margins. Clinical photo of posterior teeth showing significant gingival recession and non-carious cervical lesions. The image demonstrates aesthetic concerns and potential plaque retention areas at the cervical margins. Close-up clinical photo of a single tooth with severe gingival recession and a non-carious cervical lesion. The image emphasizes aesthetic concerns and potential plaque retention areas at the cervical margin. INDICATIONS FOR TREATMENT * Aesthetic concerns * Dentine hypersensitivity * Progressive recession * Root caries * Patient request * Pre-prosthetic or orthodontic considerations  #### Indications for Treatment - Aesthetic concerns - Dentine hypersensitivity - Progressive recession - Root caries - Patient request - Pre-prosthetic or orthodontic considerations Clinical photograph collage illustrating various periodontal conditions. The top image shows a full anterior view of the maxillary and mandibular arches with generalized gingival recession exposing root surfaces. Below are two close-up views: the left depicts significant recession on a canine tooth, while the right highlights inflamed, erythematous gingiva surrounding an exposed root surface. # Management ## Non-Surgical * Oral hygiene modification * Desensitising agents * Monitoring * Risk factor control     ##### Non-Surgical Management - Oral hygiene modification - Desensitising agents - Monitoring - Risk factor control Clinical photo showing a hand holding a wooden toothbrush with green desensitizing paste on the bristles. The background is blurred, emphasizing the toothbrush as a tool for oral hygiene modification. Photo of Sensodyne Repair & Protect toothpaste box, representing desensitising agents used in non-surgical management. Photo of Colgate Sensitive Pro-Relief toothpaste box, another example of desensitising agents for managing sensitivity. Photo of Duraphat 22,600 ppmF Sodium Fluoride Varnish tube, illustrating risk factor control through high-concentration fluoride application. Surgical Root Coverage Procedures Coronally Advanced Flap (CAF) Gold standard for RT1 defects ##### Coronally Advanced Flap (CAF) - Considered the gold standard for RT1 defects. Clinical procedure image demonstrating Coronally Advanced Flap (CAF). The image is split into two main sections: left shows 'With releasing incisions' and right shows 'Envelope flap without releasing incisions'. Each section contains before-and-after photos of teeth and gums with sutures visible, illustrating surgical root coverage steps. # Surgical Root Coverage Procedures CAF + Connective Tissue Graft (CTG) - Most predictable technique - Improves tissue thickness BILAMINAR TECHNIQUES ##### CAF + Connective Tissue Graft (CTG) - Most predictable technique - Improves tissue thickness - Utilized in bilaminar techniques Clinical procedure image series labeled 'BILAMINAR TECHNIQUES' showing three stages of a surgical root coverage procedure. The left panel shows the pre-operative state with gingival recession on anterior teeth; the middle panel depicts the intraoperative step with tissue elevation and connective tissue graft placement; the right panel illustrates the post-operative closure with sutures. Surgical Root Coverage Procedures **Free Gingival Graft (FGG)** - Increases keratinised tissue - Less aesthetic  ##### Free Gingival Graft (FGG) - Increases keratinised tissue - Less aesthetic outcome compared to other methods Clinical figure showing two side-by-side photographs under the caption 'FREE GINGIVAL GRAFT'. The left panel displays a pre-operative view of gingival recession. The right panel shows the surgical site post-grafting with sutures in place. This visual demonstrates the Free Gingival Graft procedure mentioned in the OCR text. **Surgical Root Coverage Procedures** Tunnel Technique - Minimally invasive - Suitable for multiple recessions ##### Tunnel Technique - Minimally invasive - Suitable for multiple recession defects Clinical photo series demonstrating the Tunnel Technique for Surgical Root Coverage. The sequence shows four stages: (1) pre-operative view of gingival recession on upper anterior teeth; (2) placement of an AlloDerm SELECT™ RTM graft over the tunnel; (3) post-surgical appearance with sutures in place; and (4) healed result showing root coverage. Caption reads 'AlloDerm SELECT™ RTM case images courtesy of Dr. Edward P. Allen, Dallas, Texas'. # Surgical Root Coverage Procedures Laterally Positioned Flap **LATERAL SLIDING FLAP** In a lateral sliding flap, the soft tissue mesial or distal to the exposed root is used for coverage. This technique is indicated for treatment of isolated recession defects. ##### Laterally Positioned Flap (Lateral Sliding Flap) - Soft tissue mesial or distal to the exposed root is used for coverage. - Indicated for the treatment of isolated recession defects. Clinical photograph comparison demonstrating the 'Lateral Sliding Flap' surgical root coverage procedure. The image is split into two panels: the left panel shows a clinical photo of teeth with gum recession (exposed roots), and the right panel shows the same area post-surgery with sutures in place for tissue coverage. OCR text above identifies this as a technique indicated for isolated recession defects. Prognostic Factors - Defect depth and width - Interproximal attachment level - Tissue thickness - Smoking status - Operator skill - Patient compliance  #### Prognostic Factors - Defect depth and width - Interproximal attachment level - Tissue thickness - Smoking status - Operator skill - Patient compliance A visual diagram illustrating prognostic factors in periodontal therapy. It consists of five labeled blocks arranged around a central overlapping label 'SURGICAL TECHNIQUE'. Top-left (orange): 'LOCAL ANATOMICAL CONDITIONS' with an image of teeth and gums. Top-right (purple): 'OTHER OBJECTIVES' with a close-up of gingival tissue. Bottom-left (green): 'DATA FROM THE LITERATURE' with stacked books. Bottom-right (blue): 'THE PATIENT'S REQUESTS' showing a dentist and patient consultation. - **CAF + CTG provides highest predictability for complete root coverage** - **Thick phenotype improves long-term stability** - **Long-term stability depends on plaque control and maintenance** **Periodontal Soft Tissue Root Coverage Procedures: A Systematic Review From the AAP Regeneration Workshop** Leandro Chambrone* and Dimitris N. Tatakis†  #### Evidence and Predictability - CAF + CTG provides the highest predictability for complete root coverage. - A thick phenotype improves long-term stability. - Long-term stability depends on plaque control and maintenance. Title block of a systematic review figure: 'Periodontal Soft Tissue Root Coverage Procedures: A Systematic Review From the AAP Regeneration Workshop' by Leandro Chambrone and Dimitris N. Tatakis. Part II - Gingival Overgrowth Part II - Gingival Overgrowth **Definitions** Gingival overgrowth (enlargement) is an increase in gingival volume due to inflammatory, drug-induced, systemic, or idiopathic causes.  #### Definition Gingival overgrowth (enlargement) is an increase in gingival volume due to inflammatory, drug-induced, systemic, or idiopathic causes. Clinical photo demonstrating gingival overgrowth (enlargement). The image shows significant increase in gingival volume covering the crowns of the teeth, consistent with the definition provided in the OCR text. The gingiva appears erythematous and swollen, illustrating inflammatory or drug-induced causes. **Classification** A. **Inflammatory Enlargement** * **Plaque-induced** * Chronic or acute B. **Drug-Induced Gingival Overgrowth (DIGO)** Common drugs: * **Phenytoin** * **Cyclosporine** * **Calcium channel blockers** (e.g., **nifedipine**, **amlodipine**) C. **Systemic-Associated** * **Leukemia** * Hormonal changes (**pregnancy**, **puberty**) D. **Hereditary Gingival Fibromatosis** **FIG. 88.33** **Puberty gingivitis** in a 14-year-old girl was associated with poor hygiene, crowding of teeth, and mouth breathing. Gingival hyperplasia was confined to the anterior regions. **FIG. 88.35** **Localized gingival enlargement** occurred in a 24-year-old woman who was in the seventh **month of pregnancy**. The lesion was first noticed in the fourth **month** by the patient.   #### Classification **A. Inflammatory Enlargement** - Plaque-induced - Chronic or acute **B. Drug-Induced Gingival Overgrowth (DIGO)** Common drugs include: - Phenytoin - Cyclosporine - Calcium channel blockers (e.g., nifedipine, amlodipine) **C. Systemic-Associated** - Leukemia - Hormonal changes (pregnancy, puberty) **D. Hereditary Gingival Fibromatosis** **Clinical Examples** - **Puberty gingivitis:** Associated with poor hygiene, crowding, and mouth breathing; hyperplasia typically confined to anterior regions. - **Localized gingival enlargement:** Can occur during pregnancy (e.g., appearing in the fourth month and progressing through the seventh month). Clinical photo: FIG. 88.33 shows a frontal view of the oral cavity in a 14-year-old girl with puberty gingivitis. The image demonstrates gingival hyperplasia confined to the anterior regions (front teeth). The caption notes the condition was associated with poor hygiene, crowding of teeth, and mouth breathing. Clinical photo: FIG. 88.35 displays localized gingival enlargement on the upper gumline of a 24-year-old woman during her seventh month of pregnancy. A distinct, reddish, swollen lesion is visible above the central incisors. The caption indicates the patient first noticed the lesion in the fourth month of pregnancy. # **Pathogenesis of Drug-Induced Overgrowth** - Altered fibroblast function - Increased extracellular matrix production - Reduced collagen degradation - Exacerbated by plaque accumulation - Genetic susceptibility plays a role --- **FIG. 19.6** Survey section of chronic inflammatory gingival enlargement shows the inflamed connective tissue core and strands of proliferating epithelium.  #### Pathogenesis of Drug-Induced Overgrowth - Altered fibroblast function - Increased extracellular matrix production - Reduced collagen degradation - Exacerbated by plaque accumulation - Genetic susceptibility **Histological Features** - Chronic inflammatory enlargement shows an inflamed connective tissue core and strands of proliferating epithelium. FIG. 19.6 Survey section of chronic inflammatory gingival enlargement shows the inflamed connective tissue core and strands of proliferating epithelium. **FIG. 19.1** Chronic inflammatory gingival enlargement localized to the anterior region. **FIG. 5.5** A 12-year-old female with a primary medical diagnosis of leukemia that exhibits swollen/spongy gingiva. **FIG. 5.7** Clinical images of gingival overgrowth following use of a calcium channel blocker to control hypertension.     #### Clinical Presentations - **Chronic inflammatory enlargement:** Often localized to the anterior region. - **Leukemia-associated enlargement:** Presents as swollen or spongy gingiva. - **Calcium channel blocker-induced overgrowth:** Resulting from medication used to control hypertension. Clinical photo (FIG. 19.1) showing chronic inflammatory gingival enlargement localized to the anterior region. Clinical photo (FIG. 5.5) of a 12-year-old female with leukemia exhibiting swollen/spongy gingiva. Clinical photo (FIG. 5.7A) of gingival overgrowth following use of a calcium channel blocker. Clinical photo (FIG. 5.7B) of gingival overgrowth following use of a calcium channel blocker. Complications Plaque retention Pseudopockets Difficulty in oral hygiene Aesthetic compromise Impaired mastication Speech interference (severe cases) FIG. 5.6 Clinical images of a 9-year-old male with severe gingival overgrowth.  #### Complications - Plaque retention - Pseudopockets - Difficulty in oral hygiene - Aesthetic compromise - Impaired mastication - Speech interference (in severe cases) FIG. 5.6 Clinical images of a 9-year-old male with severe gingival overgrowth secondary to heart transplant and cyclosporine therapy. The figure is composed of four panels (A, B, C, D) showing close-up views of the patient's oral cavity. Panel A shows the anterior upper and lower teeth with significant red, bulbous gum tissue covering the crowns. Panel B provides a detailed view of the upper arch where the gums have overgrown extensively, leaving only small portions of the teeth visible. Panels C and D show the lower anterior region, highlighting the inflamed and hypertrophic gingiva. # Management ## A. Non-Surgical * Intensive plaque control * Scaling and root planing * Chlorhexidine adjunct * Liaise with physician for medication substitution ## B. Surgical Management **Indicated when:** * Fibrotic component persists * Functional/aesthetic compromise * Persistent pseudopockets **Procedures:** * Gingivectomy (external bevel) * Internal bevel gingivectomy * Flap surgery if true pockets present * Laser excision (selected cases) **FIG. 61.5** Periodontal flap treatment for drug-induced gingival enlargement. (A) Initial reverse bevel incision followed by thinning of the enlarged gingival tissue; dotted lines represent incisions, and the *shaded area* represents the tissue portion to be excised. (B) After flap elevation, the enlarged portion of the gingival tissue is removed. (C) The flap is placed on top of the alveolar bone and sutured.  #### Management Strategies **Non-Surgical Management** - Intensive plaque control - Scaling and root planing - Chlorhexidine adjunct - Liaison with physician for medication substitution **Surgical Management** Indicated when a fibrotic component persists, there is functional/aesthetic compromise, or persistent pseudopockets are present. Procedures include: - Gingivectomy (external or internal bevel) - Flap surgery (if true pockets are present) - Laser excision - Periodontal flap treatment: Involves reverse bevel incision, thinning of enlarged tissue, and suturing the flap to the alveolar bone. FIG. 61.5 Periodontal flap treatment for drug-induced gingival enlargement. The figure displays three panels labeled A, B, and C illustrating a surgical sequence: (A) Initial reverse bevel incision followed by thinning of the enlarged gingival tissue; dotted lines represent incisions, and the shaded area represents the tissue portion to be excised. (B) After flap elevation, the enlarged portion of the gingival tissue is removed. (C) The flap is placed on top of the alveolar bone and sutured. # Recurrence - Common in DIGO - Dependent on: - Drug continuation - Plaque control - Genetic factors <img style="color:transparent" src="https://lh3.googleusercontent.com/pw/ABKH3CKdMV2Xj7-cZwVeIeBPfqFxGorMYK7XmAHZ6A4Opkx6W1jE1M6V-kGjWQd5O3y6wUoH0oV4m7Qm7rW0Yj5JqG8_34UyU1H2heB1g5q8f0h9O9a5G9H4X5k6z7A6b8C7d=Ew1M9AX4/pw/ABKH3CKdMV2Xj7-cZwVeIeBPfqFxGorMYK7XmAHZ6A4Opkx6W1jE1M6V-kGjWQd5O3y6wUoH0oV4m7Qm7rW0Yj5JqG8_34UyU1H2heB1g5q8f0h9O9a5G9H4X5k6z7A6b8C7d=Ew1M9AX4/http/images.lh5.googleusercontent.com/pw/ABKH3CKdMV2Xj7-cZwVeIeBPfqFxGorMYK7XmAHZ6A4Opkx6W1jE1M6V-kGjWQd5O3y6wUoH0oV4m7Qm7rW0Yj5JqG8_34UyU1H2heB1g5q8f0h9O9a5G9H4X5k6z7A6b8C7d=Ew1M9AX4/http/images.lh5.googleusercontent.com/pw/ABKH3CKdMV2Xj7-cZwVeIeBPfqFxGorMYK7XmAHZ6A4Opkx6W1jE1M6V-kGjWQd5O3y6wUoH0oV4m7Qm7rW0Yj5JqG8_34UyU1H2heB1g5q8f0h9O9a5G9H4X5k6z7A6b8C7d=Ew1M9AX4/http/images.lh5.googleusercontent.com" alt="Dental illustration showing tooth brushing and medication" data-name="recurrence">  #### Recurrence Recurrence is common in Drug-Induced Gingival Overgrowth (DIGO) and is dependent on: - Continuation of the associated drug - Quality of plaque control - Genetic factors Dental illustration showing tooth brushing and medication. The image depicts a cartoon-style tooth being brushed by a blue toothbrush with white bristles, surrounded by sparkles to indicate cleanliness. Below the tooth is pink gum tissue. To the right are two medicine bottles—one red with an 'Rx' symbol and one yellow with a red cross—and scattered pills in blister packs and loose capsules. # Key Take-Home Message * Gingival recession is primarily a soft tissue deficiency problem. * Predictability depends on interproximal attachment. * Gingival overgrowth is often plaque-modified and drug-associated. * Maintenance therapy is critical for both conditions. #### Key Take-Home Messages - Gingival recession is primarily a soft tissue deficiency problem. - Predictability of treatment depends on interproximal attachment. - Gingival overgrowth is often plaque-modified and drug-associated. - Maintenance therapy is critical for the long-term management of both conditions. [^1]: Original PDF page 1: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=1|L2 Gingival Recession Gingival Overgrowth, p.1]] [^2]: Original PDF page 2: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=2|L2 Gingival Recession Gingival Overgrowth, p.2]] [^3]: Original PDF page 3: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=3|L2 Gingival Recession Gingival Overgrowth, p.3]] [^4]: Original PDF page 4: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=4|L2 Gingival Recession Gingival Overgrowth, p.4]] [^5]: Original PDF page 5: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=5|L2 Gingival Recession Gingival Overgrowth, p.5]] [^6]: Original PDF page 6: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=6|L2 Gingival Recession Gingival Overgrowth, p.6]] [^7]: Original PDF page 7: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=7|L2 Gingival Recession Gingival Overgrowth, p.7]] [^8]: Original PDF page 8: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=8|L2 Gingival Recession Gingival Overgrowth, p.8]] [^9]: Original PDF page 9: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=9|L2 Gingival Recession Gingival Overgrowth, p.9]] [^10]: Original PDF page 10: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=10|L2 Gingival Recession Gingival Overgrowth, p.10]] [^11]: Original PDF page 11: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=11|L2 Gingival Recession Gingival Overgrowth, p.11]] [^12]: Original PDF page 12: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=12|L2 Gingival Recession Gingival Overgrowth, p.12]] [^13]: Original PDF page 13: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=13|L2 Gingival Recession Gingival Overgrowth, p.13]] [^14]: Original PDF page 14: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=14|L2 Gingival Recession Gingival Overgrowth, p.14]] [^15]: Original PDF page 15: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=15|L2 Gingival Recession Gingival Overgrowth, p.15]] [^16]: Original PDF page 16: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=16|L2 Gingival Recession Gingival Overgrowth, p.16]] [^17]: Original PDF page 17: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=17|L2 Gingival Recession Gingival Overgrowth, p.17]] [^18]: Original PDF page 18: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=18|L2 Gingival Recession Gingival Overgrowth, p.18]] [^19]: Original PDF page 19: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=19|L2 Gingival Recession Gingival Overgrowth, p.19]] [^20]: Original PDF page 20: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=20|L2 Gingival Recession Gingival Overgrowth, p.20]] [^21]: Original PDF page 21: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=21|L2 Gingival Recession Gingival Overgrowth, p.21]] [^22]: Original PDF page 22: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=22|L2 Gingival Recession Gingival Overgrowth, p.22]] [^23]: Original PDF page 23: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=23|L2 Gingival Recession Gingival Overgrowth, p.23]] [^24]: Original PDF page 24: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=24|L2 Gingival Recession Gingival Overgrowth, p.24]] [^25]: Original PDF page 25: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=25|L2 Gingival Recession Gingival Overgrowth, p.25]] [^26]: Original PDF page 26: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=26|L2 Gingival Recession Gingival Overgrowth, p.26]] [^27]: Original PDF page 27: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=27|L2 Gingival Recession Gingival Overgrowth, p.27]] [^28]: Original PDF page 28: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=28|L2 Gingival Recession Gingival Overgrowth, p.28]] [^29]: Original PDF page 29: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=29|L2 Gingival Recession Gingival Overgrowth, p.29]] [^30]: Original PDF page 30: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=30|L2 Gingival Recession Gingival Overgrowth, p.30]] [^31]: Original PDF page 31: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=31|L2 Gingival Recession Gingival Overgrowth, p.31]] [^32]: Original PDF page 32: [[L2 Gingival Recession Gingival Overgrowth.pdf#page=32|L2 Gingival Recession Gingival Overgrowth, p.32]]