(27) Periodontal Pre-orthodontic Treatment: Enhancing Gingiva Phenotype

Introduction: The presence of a thin gingival phenotype has been associated with a higher risk of gingival recession and bony dehiscence. The current consensus from the American Academy of Periodontology states that ≥ 2 mm of keratinized tissue (KT) and ≥ 1mm of attached gingiva around teeth are needed to maintain periodontal health, especially in patients with poor plaque control.
Orthodontic treatment might pose a potential risk for periodontal tissues, such as the gingival recession. It has been reported that the orthodontic tooth movement to positions outside the alveolar bone housing can cause thinning of the buccal or lingual plate, which can lead to dehiscence or fenestration. Consequently, gingival apical migration will occur without alveolar bone support, resulting in root exposure.
A thorough periodontal assessment of pre-orthodontic treatment is essential to evaluate the need for a phenotype modification therapy. Soft tissue augmentation with the purpose of increasing the amount of KT is recommended to avoid or prevent a future gingival recession. Autogenous free gingival graft (FGG) is considered the gold standard for augmenting gingival tissue and thus enhancing gingival phenotype. This case report presents a predictable method to improve the gingival phenotype, reducing the potential complications after orthodontic treatment.

Methods: A 56-year-old female patient (ASA II) with a history of orthodontic treatment 20 years prior to presentation was evaluated for teeth alignment. Upon periodontal examination, the patient was diagnosed with generalized mild chronic periodontitis and mucogingival deficiency: gingival recession and lack of KT on the mandibular anterior teeth, including first premolars. A 1.25 mm thick FGG was harvested from the palate and transferred to the recipient sites to enhance the gingival phenotype before orthodontic treatment (no root coverage was attempted).

Results: The mucogingival condition was evaluated at 3 and 12 months follow-up appointments. No complications were noticed, and significant improvements in the gingival phenotype were seen in the recipient site. The KT has improved from 1mm up to 7mm, and the gingival phenotype improved from thin to thick.

Conclusions: Gingiva phenotype modification by soft tissue augmentation in patients with poor plaque control, should be performed in areas with < 2mm of KT before initiation of orthodontic therapy if the foreseen orthodontic movements would position the teeth out of the bony envelope, preventing root exposure.

Lead Author's Contributions to the Research Project. : The Lead Author was responsible for the data collection.