Pédiatrie Dentistry

Fenestration gingival defect in ernpting permanentmandibular incisors: A case reportLourdes A. M. Santos-Pinto*/N. Sue Seale**/Ani] K. Reddy*^!=*/Rita C. L.

Bilateral fenesiraüon of the labial gingival tissue of the permanent mandibular central incisors ix describedThe situation wasfolkm-ed over a 2-year period with no treatment other than prophylaxis and oral hygieneinstruction. The final outcome was an apical positioning of the gingival margin, which was lower than !ha!of the adjacent unimotved teeth. (Qtiintessenee Int 1998;29:239-242)

Key «ords: fenestration. gingival margin, gingival recesíiion. tooth eruption

G ingiva! recession has been defined as the conditionin which the gingival margin is located apical to

the cementoenamel junction and there is partial denuda-tion of the root surface. In the past decade, the designa-tion pseiidorecessioti has been applied to those casesshowing apical migration of the gingival margin, com-pared to adjacent teeth, but without exposure of the rootsurface, '

Localized gingival recession in the mandibularincisor region is frequently found in younger patientsduring tooth eruption. The prevalence varies widely, ac-cording to several studies.'^ The reasons for this varia-tion are differences in the definitions of recession andpseudorecession, as well as variations in patient age,patient ethnicity, and area of the mouth studied. The

"Professor, Department of Pédiatrie Denlistry and Orthudontics,University of Slo Paulo, Araraquara, Sao Paulo, Brazil; VisitingProfessor, Department of Pedialric Dentistry, Baylor College ofDentistry, Texas AÜM University System, Dallas, Texas,

"Associate Professor and Chairman, Department of PédiatrieDentistry, Baylor College of Dentistry. Tesas A&M UniversitySystem. Dallas. Texa,s.

***Assislai)t Professor, Department of Pédiatrie Dentistry. BaylurCollege of Denti,strj', Texas A&M University System, Dallas. Texas,

'**'Professor, Department of Pédiatrie Dentistry and Orthodonlici,University of Sao Paulo, Araraquara, Sao Paulo, Brazil.

Reprint requests: Dr Anil K, Reddy, Dipartment of Pédiatrie Dentistry,Baylor College of Dentistry, PO Bos 660677. Dallas, Te*a.s. 75266-0677,Fa);:214-S28-SI32.

prevalence of reces.sion in the mandibular incisor tegionranges from 19!: to 10% for true recession'- and from17% to SO*!?: for pseudorecession.'-'

The etiology of recession is not completely under-stood, although rotation or labial displacement of theteeth, the width of the keratinized and attached gingiva,and a high frenum attachment are all considered predis-posing factors. Inflammatory periodontal disease, tooth-brush trauma, and trautna from occlusion have beenidentified as precipitating factors in the process ofrecession.^-'^

Few longitudinal studies have evaluated the gingivalmorphology of the mandibular incisor region in the de-veloping dentition. During the developrnent of the den-tition, the gingival height and width increase because ofthe growth in the aiveoiar process and the altered posi-tion of the teeth in the alveolar process. Also, sponta-neous changes of the tooth position in the buccolingualdirection, which often occur during development, willaffect gingival height,"

This ca.se report describes changes in the gingivalmorphology of the mandibular incisors during the stageof active eruption in a 6-year-old boy.

Case report

A 6-year-old boy presented for his first clinical exami-nation with a Class I molar relationship, unerupted per-manent maxillary incisors, and permanent mandibular

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central incisors in an early stage of eruption. The in-cisors were labially positioned (0.5 mm) in relation tothe incisai edge of the primary lateral incisors andcanines. No clinical signs of gingivitis were lound, anda fenestration was observed in the labial gingiva of thepermanent mandibular right central incisor (Fig I).

The patient's history revealed no trauma or other fac-tors that could have caused the fenestration. No oppos-ing teeth were present at the first examination. Probepenetration sbowed tbai tbe gingival tissue above thefenestration was not attached to the tooth, and the prob-ing depth in the gingival sulcus was 1.0 mm (Fig 2).

Six mouths later, the patient was ree\amined. and thefenestration had increased in all dimensions and hadbecotne rounded. The gingival tissue ahove the fenes-tration was narrower and thinner (Fig 3). Four monthslater, when the patient was 6 years 10 months old, theupper tissue band was gone and pseudorecession waspresent with more evident gingivitis (Fig 4).

The patient was reexamined 8 months later, when hewas 7 years 6 months old. The pertnauent mandibularlateral incisors were erupting, and he presented withslight mandibular anterior crowding, increased marginalgingivitis, and enlarged interdental papillae. The leftcentral incisor had begun to demonstrate the same kindof fenestratioti as the right incisor (Fig 5). Six monthslater, the gingival margins of the incisors were posi-tioned similarly, the sulcus depths were I mm, and thegingivitis was still present (Fig 6).

Discussion

There is little information in the literature about de-velopmental changes in the morphology of the gingivalunit during the mixed dentition period. During perma-nent tooth eruption, apical movement of the gingivalmargin does not correspond to the amount of occlusalmovement of the teeth. Some dimensional changes canoccur and may be influenced by the stage of eruption,the position of the teeth in relation to the buccolingualdimension of the alveolar process, and the presence ofgingival inflammation.'̂ ''-^

This patient showed slight mandibular anteriorcrowding and labial positioning of the permanent cen-tral incisors. A significant association between the toothposition in tbe arch and mandibular incisor recessionhas been reported by a nnmber of autbors.'-"'"•"-"•"'These studies have confirmed that teeth positioned labi-ally in the dental arches are predisposed to localizedrecession of the labial gingiva.

Injury to the gingival tissue is most often the resultof toothbrusb trauma. Mai positioned teetb and tooth-brush trauma were found by Gorman'' to be the most

frequent factors a,ssociated with gingival recessioti. Therole of traumatic occlusion in gingival recession is nolclear. Woofter"< did not consider traumatic occlusion animportant factor in gingival recession, while Geiger"concluded that premature contact in centric closure inpatients with crossbite or edge-to-edge occlusion cancontribute to crestal alveolar bone loss, resulting inlocalized recession. None of these factors was identifiedin the patient in this case report.

Inflammatory periodontal diseases have been consid-ered an etiologic factor in gingival recession.'•'•^•'•"^Powell and McEniery"̂ suggested that gingival inflatn-mation itself may lead to recession, and associated fac-tors, such as crowding, may accelerate the proces.s. Thispatient did not show gingival inflammation at the firstexamination; inflammation of the marginal gingiva withenlargement of the interdental papillae became evidentafter complete fenestration of tbe gingival tissue.

Another possible etiologic factor to be considered isfrenal involvement. Powell and McEniery' found no sig-nificant association between high frenum pull andmandibular incisor recession. However, Stoner andMazdyasna' reported that frenal pull was the secondmost frequently associated factor in gingival recession.No frenal pull or high muscle insertion was identified inthe patient in the present report.

Some studies have demonstrated that gingival reces-sion of the labial surfaces of the mandibular central inci-sors in the mixed dentition is reduced over time.'-'*According to Andlin-Sobocki et al,'-* localized gingivalrecession in the mandibular region in children may im-prove without special measures. Developmental changesin the dentition during growth, favoring incisor align-ment, may contribute to a reduction of the recession.Poweir reported that control of marginal inflammationappeared to be the most important measure in limitingprogressive recession.

Moriarty'- commented that critical evaluation ofphotographs in articles claiming an improvement in gin-gival recession reveals that the improvement in theamount of recession can result from resolution of in-flammation or reduction of pseudorecession by passiveeruption of the adjacent teeth and attrition.

No special effort was directed in the treatment of thegingival condition of this patient, with the exception ofprofessional oral hygiene supervision, which wasreinforced every 3 months. The parents were instructedto help their son brush his teeth before going to sleepeach night.

There are a variety of approaches to the managementof localized gingival recession in children. Gingivalrecession is not associated with one singie factor, andassessmetit of predisposing factors such as clinical eval-

240 Volume 29, Number 4, 1998

Fig 1 A fenestration (arrow) is present at the mandibu-lar right central incisor of a 6-year-old boy. The incisorsare labially positioned, and no infiammation is evident

Fig 2 A periodontal probe insetted in!o the gingiuaitissue of the mandibular right central incisor reveals thatthe gingiva is not attached to the tooth

Fig 3 SIX months later, the fenestration has increased,and ihe tissue above the fenestration (arrow) is fhinrierand narrower (patient aged 6 years 6 months)

Fig 4 Four mortths later, pseudorecession and siightgingivitis are present (patient aged 6 years 10 months).

Fig 5 Eight months latei, gingivitis and enlarged inter-denfai papiila are present (small arrows), and a fenes-tration has appeared at the adjacent tooth (large arrow)(patient aged 7 years 6 months].

Fig 6 Two years after the initial findings, similar gingi-vai margin positions, gingivitis, and enlarged interdentalpapillae have persisted (patient aged 8 years).

uation of keratinized and attached gingiva, facial-to-lingual dimension of both soft tissue and alveolus, andangulation of the teeth and positioning within the bonehousing should be considered before treatment deci-sions are made. Precipitating factors related to marginalinflammation and the amount of trauma imposed ongingival tissue could enhance or reduce the potential forrecession.'-

Conservative therapy consists of oral hygiene in-struction and prophylaxis. This treatment is based on theconcept that recession reflects a precocious mamrity ofthe gingival margin of the affected tooth and that, giventime, the adjacent teeth will achieve a similar gingivamarginal level.'" Andlin-Sobocki et al'-' observed thatgingival recession in mandihular incisors in young chil-dren often improved over time when an appropriate level

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Santos-Pinto et al

of oral hygiene was maintained. Improvement in reces-

sion was also observed in patients who had regular pro-

fessional plaque control.' We conclude that decisions

regarding treatment should wait until time has been

allowed for spontaneous improvement.

Conclusion

Bilateral fenestration of tbe labial gingival tissue of the

permanent mandibular central incisor.s was followed,

without special treatment or intervention, over a 2-year

period. The final outcome was an apical positioning of

tbe gingival margin, which was lower than that of the

adjacent uninvolved teeth. Additionally, low-grade mar-

ginal gingivitis developed atid persisted over time, in

spite of good oral hygiene. No precipitating factors,

such as traumatic occlusion, were identified. The only

etiologic factor pre.sent was the labial positioning of the

involved teeth.

The supporting tissues of the teeth in the growing

child are under a continuous process of remodeling.

Because of this dynamic situation, repeated clinical

evaluations are needed. If the teeth change position so

that the roots become more prominent, prophylactic

gingival grafting should be considered.

References

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2. Younes SAS, Anghawi MF. Gingival nícession in Ihe mandibularcentral incisor region of Saudi schoolchildren aged 10-15 years,Community Dent Oral Epidemiol 1983;! 1:246-249,

3. Trott JR, Love B. An analysis of localized gingival rece.ssion in766 Winnipeg high school .iludents. Dent Pract I966;I6:2O9-2I3.

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5. Baker DL, Seymour GJ. The possible pathogenesis of gingivalrecession. J Glin Periodontol I976;3:2O8-219.

6. Powell RN, McEniety TM. Disparities in gingival height in themandibular central ineisor region of children aged 6-12 years.Community Dent Oral Epidemiol iy81;9:32-36.

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12. Moriarty JD. Mucogingival considerations for the orthodonticpatient. Gurr Opin Periodontol 1996;3:97-IO2.

13. Wennström JL. Mucogingival considerations in orthodontietreatment. Semin Orthod 1996;2:46-54.

14. Andlin-Sohocki A, Marcusson A. Persson M. Three-year obser-vations on gingival recession in mandibular incisors in children,J Clin Periodontol 1991:18:155-159.

15. Bimslem E, Eidelman E. Morphological changes in the atlachedand keratinized gingiva and gingival sulcus in ihe miüed denti-tion period. J Clin Periodonlol 1988:15:175-179.

16. Harrison RL, Legott PJ, Kennedy DB, Lowe AA, Robertson PB.The association of simple anterior dental eros.sbite to gingivalmargin discrepancy. Pediatr Dent I991;I3:296-3OO.

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