ORIGINAL ARTICLE

The role of orthodontics in the repair of

gingival recessions
Morten Godtfredsen Laursen,a,b Mette Rylev,b and Birte Melsenc,d
Aarhus, Denmark, and L€
ubeck and Hannover, Germany

Introduction: The goal of this research was to assess the impact of orthodontic root movement on gingival re-
cessions. Methods: Twelve consecutive adult patients with a mandibular incisor presenting buccal or lingual
gingival recession and with the root positioned outside the alveolar bone were enrolled. The roots were moved
toward the center of the alveolar process with a goal oriented segmented appliance. The following variables were
measured at baseline and after orthodontic treatment: (1) recession depth, (2) recession width, and (3) recession
area. In addition, pocket probing depth, keratinized tissue height, and changes in Miller's classification were
registered. Results: The depth, width, and area of the gingival recessions were reduced in all patients without
increased pocket probing depth. On average, the recession depth decreased with 23%, the width with 38%, and
the recession area with 63% of the baseline value. All patients improved in Miller's classification from Class III
and IV to Class I or II. Conclusions: Orthodontic correction of the root toward the center of the alveolar envelope
consistently reduced gingival recessions. The changes in Miller's classification indicated improved prognosis for
full root coverage with mucogingival surgery. (Am J Orthod Dentofacial Orthop 2020;157:29-34)

T
ooth displacement outside the alveolar bone con-
stitutes a risk for the development of a bony dehis-
cence that may be accompanied by a recession of
the gingiva.1-6 Conversely, redirection of a root into the
alveolar process can be complemented by improved
marginal bone level1,4,5,7,8 and spontaneous
improvement of gingival recession.9-12 According to
several authors, the prognosis for a complete root
coverage of gingival recessions by a mucogingival
surgical intervention is correlated to both the severity
of the recession13-17 and the position of the recessed
tooth.13 Consequently, it is advocated to position the
roots within the alveolar envelope reducing root promi-
nence and allowing creeping of the attachment thereby
providing a more optimal surgical site.18 Movement of
a
Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus Uni-
versity, Aarhus, Denmark.
b
Private practice, Aarhus, Denmark.
c
Formerly, Section of Orthodontics, Department of Dentistry and Oral Health,
Aarhus University, Aarhus, Denmark; currently, Medizinische Hochschule, Hann-
over, Germany.
d
Private practice, L€
ubeck, Germany.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Morten Godtfredsen Laursen, Section of Orthodon-
tics, Department of Dentistry and Oral Health, Aarhus University, Vennelyst
Boulevard 9, Aarhus C DK-8000 Denmark; e-mail, morten.godtfredsen.
laursen@dent.au.dk.
Submitted, April 2018; revised and accepted, January 2019.
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.01.023
the exposed roots toward the center of the alveolus
may thus lead to improvement of the gingival recession
and to reduction of the bony dehiscence before peri-
odontal plastic surgery.12 However, the association be-
tween orthodontic correction of tooth position and
“spontaneous” repair of gingival recession has not previ-
ously been systematically investigated in a clinical study.
The aim of this study was to quantify the changes of
gingival recessions following orthodontic displacement
of exposed roots toward the center of the alveolar
bony envelope.
MATERIAL AND METHODS
Twelve consecutive adult patients (9 females and 3
males), mean age of 28 years and age range 22-
41 years, with 1 mandibular incisor presenting either
buccal or lingual gingival recession and the root clearly
positioned outside the alveolar bone were enrolled for
orthodontic root correction before mucogingival sur-
gery. Apart from the gingival recession of the displaced
incisor, none of the patients exhibited periodontal
inflammation, radiological signs, or clinically detect-
able defects, which would indicate a past history of
periodontitis. Informed consent to participate in the
study was obtained. The orthodontic root corrections
were performed with a segmented appliance consisting
of a torque arch made of 0.019 3 0.025-inch titanium-
molybdenum alloy delivering a desired torque equal to
the force applied to hook the arch onto the base arch
29
30 Laursen, Rylev, and Melsen

Fig 1. A and B, Root of the mandibular left central incisor (tooth 31) positioned outside the alveolar
housing exhibiting gingival recession. C, Beginning of treatment. The force system, generating lingual
root torque of the incisor, without side-effect on adjacent teeth, was obtained by a 0.019 3 0.025-inch
titanium-molybdenum alloy torque arch inserted into the bracket of the malpositioned tooth and hooked
onto a 0.020-inch SS base arch that controlled the vertical position of the incisor and the arch perimeter.
D, During lingual root torque of tooth 31. The root of 31 is moving into the alveolar bone. E, One week
after orthodontic treatment. The root position is corrected, and the recession is reduced in depth and
width. SS, stainless steel.

anteriorly to the molar multiplied by the sagittal dis-
tance between the displaced tooth and the point of
force application. The undesired vertical force was
neutralized by a steel base arch resting on the displaced
tooth (Figs 1-3). The base arch also prevented
undesired proclination during lingual root torque and
undesired retroclination during buccal root torque. As
a consequence, only the torque needed for the root
movement was expressed, and the center of rotation
was at the bracket without side effects on the
adjacent teeth. In some patients, finishing corrections
were performed with a continuous wire (Fig 3, C). All
patients were treated by the same orthodontist. After
orthodontic treatment, the patients were referred to
the periodontist for mucogingival surgery (Fig 3, D).
At baseline and after orthodontic treatment, the
following variables were measured clinically with a cali-
brated periodontal probe (University of North Carolina-
15 probe) and on standardized intraoral photographs:
(1) recession depth from the free gingival margin to
the cemento-enamel junction, (2) recession width at
the cemento–enamel junction, (3) recession area (on
photographs), and (4) keratinized tissue height at the
midbuccal or midlingual aspect of the exposed root.
Furthermore, pocket probing depth was measured using
the same calibrated periodontal probe also at the

January 2020  Vol 157  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Laursen, Rylev, and Melsen
Fig 2. The appliance with the torque arch deactivated.
The terminal ends of the torque arch are hooked onto
the base arch for lingual root torque of the incisor. The
base arch is activated for intrusion of the incisor to coun-
teract extrusion. The tendency to displace the incisor labi-
ally during lingual root torque is controlled by cinching
back the base arch distal to the molars.
midbuccal or midlingual aspect, and the recessions were
classified according to Miller's classification.13
The measurements were performed by the referring
periodontist and the orthodontist treating the patients.
The reported measurements of recession width and
depth were made to the nearest 0.25 mm on magnified
(factor 10) intraoral photographs of good quality and
calibrated to the true value using the clinically assessed
widths of maxillary and mandibular incisors as reference.
The area of the recession was calculated on the clinical
photographs with an open source image processing
software (ImageJ, version 2.0.0; National Institutes of
Health, Bethesda, MD). Measurements on the photos
were repeated after a minimum of 15 days on 12 patients
for calculation of the error of the method.
Statistical analysis
The mean and range of the intraindividual changes in
recession depth, width, and area were calculated. Intra-
examiner reproducibility was assessed by interclass cor-
relation coefficient. Bland-Altman plots were inspected
for the systematic error and the Dahlberg's formula
was used for the calculation of the random error. The
analysis was performed using Stata software version
14.1 (StataCorp, College Station, Tex).
RESULTS
Excellent reliability was shown when comparing 2
complete sets of measurements with an interclass corre-
lation coefficient ranging from 0.993 to 0.999. Bland-
Altman plots revealed no systematic errors for any of
the performed measurements of recession depth, width,
and area. The random error calculated by the Dahlberg's
formula was 0.07 mm for the recession depth and
0.08 mm for recession width and 0.15 mm2 for the area.
American Journal of Orthodontics and Dentofacial Orthopedics
31
The width, depth, and area of the gingival recessions
were reduced in all patients. The changes in the individ-
ual patients are illustrated graphically (Fig 4, A-C). As a
consequence, all patients showed improvement in
Miller's classification from Class III and IV to Class I or
II. Four patients improved from Miller's Class IV to II, 1
patient from Class IV to I, 6 patients from Class III to
II, and 1 patient from Class III to I. On average, the reces-
sion depth decreased with 23% (range 4.35%-43.75%),
the recession width with 38% (range 27%-67%) and the
recession area with 63% (range 36%-93%) of the base-
line value. In 2 patients (Fig 4, A, series 9 and 11) the
depth was reduced with\10%, but the overall reduction
in width lead to more than 50% reduction in recession
area in these 2 patients. The height of the keratinized tis-
sue was at baseline #1 mm in all patients. After ortho-
dontic treatment, 7 patients did not show a measurable
increase in the height of keratinized tissue and 5 patients
demonstrated an increase of #0.75 mm, although not
corresponding to the amount of reduction in recession
depth in any case. Pocket probing depth was unchanged
with measurements #1 mm in all patients both before
and after orthodontic treatment.
DISCUSSION
Gingival recessions of mandibular incisors may be
related to displacement of the root outside the boundary
of the alveolar envelope. This report evaluates the effect
of orthodontic repositioning on the extension of the
gingival recession.
The appliance used generated a large torque moment
with small forces omitting side effects on the adjacent
teeth because these were not included in the appliance
during the correction. The vertical forces acting on the
molars were of a magnitude that was neutralized by
occlusal forces.
After orthodontic treatment, all patients had
improvement of the recession depth, width, and area
leading to an improved Miller's classification. However,
the depth was reduced \10% in 2 patients. This may
be explained by a thick lip frenulum attaching close to
the recession in these patients. Reduction in the width
nevertheless resulted in a reduced recession area also
in these patients. The recession width was measured at
the cemento-enamel junction, but the width decreased
in the entire extension of the recessions and often
more in the apical part of the recession, which is also
seen in Figures 1, A-E and 3, A-C.
The reduction of recessions following root movement
toward the center of the alveolar process confirmed the
findings of previous animal studies7 and human case re-
ports.2,9-11 For ethical reasons, regeneration of the
January 2020  Vol 157  Issue 1
32 Laursen, Rylev, and Melsen

Fig 3. A, Root of the mandibular right central incisor (tooth 41) positioned outside the alveolar housing
and with gingival recession. B, The appliance delivers lingual root torque to tooth 41 with a torque arch
inserted into the bracket of the displaced tooth and hooked onto a base arch that controlled the vertical
position of the incisor and the arch length. C, Before referral back to the periodontist after finishing in a
continuous arch wire. D, Five months after mucogingival surgery with a coronally advanced flap com-
bined with enamel matrix proteins.

Fig 4. A, Reduction in recession depth illustrated for each of the 12 patients. The points on the left indi-
cate the values before treatment and the points on the right indicate the posttreatment value. All
patients presented with a reduction in recession depth. Patients 2 and 5 have the same values and
are represented by series 5. B, Reduction in recession width. All patients obtained a reduction in reces-
sion width. Patients 7, 9, and 12 have the same values and are represented by series 12. Patients 5 and
8 have the same values and are represented by series 8. Patients 2 and 11 have the same values and
are represented by series 11. C, Reduction in recession area varied considerably, but all patients
exhibited an improvement.

marginal bone level could not be assessed in this study, before and after the orthodontic root correction. This
but an improvement was observed by the periodontist in finding is supported by the findings of animal
1 patient, where a periodontal flap was raised both studies1,4,5,7,8 and a human case report by Pazera

January 2020  Vol 157  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Laursen, Rylev, and Melsen
et al,2 where the correction of a root displaced out of the
alveolar housing resulted in the regeneration of bone. A
cone beam computed tomography (CBCT) evaluation of
changes in the marginal bone level was not performed
because the thickness of the alveolar bone plate could
be expected to be below the imaging spatial resolution
of the CBCT scanning. Therefore, a CBCT evaluation
would expectably lead to false findings19,20 and thus
not indicated or ethical. A control group was not
included because of the risk of progression of
recessions when left untreated.21 The prognosis for a
complete root coverage by periodontal plastic surgery
has been reported to be correlated to the severity of
the recession.13-17 According to the classification by
Miller,13 the Class III defects have the gingival margin
located at or beyond the mucogingival junction with
interproximal bone loss and/or tooth malpositioning.
The Miller Class IV defects are defined by serious
interproximal bone loss and/or severe tooth
malpositioning.13,22 Defects classified as Class III or IV
cannot, according to Miller,13 be treated to complete
root coverage by mucogingival surgery. However, Class
I and II recessions can be fully covered with mucogingi-
val surgery. In this study, the recessions classified as
Miller Class III and IV because of tooth malposition
beyond the bony alveolar housing. The orthodontic
treatment directed the roots to the center of the alveolar
process and converted the Miller classification of the re-
cessions to Class I or II, and thus a more favorable start-
ing point for periodontal plastic surgery.
All cases in the present study exhibited a “sponta-
neous” improvement of the connective tissue coverage,
and some patients might not even need surgical inter-
vention following orthodontic correction with “sponta-
neous” repair of the recession. However, the reduction in
recession depth did not result in increased height of the
keratinized tissue in most patients, which can be related
to a modest reduction in recessions depth. The pocket
probing depth was #1 mm both before and after ortho-
dontic treatment, which possibly can suggest that the
periodontal ligament migrates coronally leading to an
improvement of the clinical attachment level.
The results demonstrate the potential synergy of an
interdisciplinary orthodontic and periodontal treatment
of patients with gingival recessions related to roots posi-
tioned outside the alveolar bony housing. Moving the
roots first to an ideal position within the alveolar process
can reduce the recession and improve the prognosis for
following mucogingival surgical intervention. The mea-
surements of recession dimensions were performed on
magnified intraoral photos. A possible limitation of this
method could be the orientation of the photos. However,
the photos were standardized, and the applied method
American Journal of Orthodontics and Dentofacial Orthopedics
33
has been evaluated in a previous study23 demonstrating
that measurements of gingival recessions are reliable on
clinical photographs. Clinical measurements of recession
dimensions are not reported because there was no
assessment of repeatability and reproducibility for those,
but the clinical measurements in the sample generally
reflected the measurements performed on photographs.
If clinical measurements of recessions should be consid-
ered the “gold standard,” indeed, the validity and repro-
ducibility of using photographs and ImageJ to evaluate
the percentage of root coverage have been assessed by
Kerner et al,24 who found the method highly correlated
with clinical measurements. The sample size was limited
owing to the inclusion criteria, and only mandibular
incisors were investigated in the current study. Presum-
ably, the results can be applied to other tooth types as
reported by other authors.2,7
Applicability of the findings can be discussed since
baseline recession dimension and incisors displacement
varied, and individuals tend to have different responses
to the same treatment. Nevertheless, the reaction shared
by all patients was a reduction of the recession width,
depth, and area following orthodontic movement of
the root toward the center of the alveolar process. The
amount of orthodontic displacement into the alveolar
process can sometimes be limited by the buccolingual
thickness of the alveolar process, and care should then
be taken not to displace the root out of the bone on
the opposite side of the recession.
CONCLUSIONS
The findings of this study indicate that orthodontic
correction of roots positioned outside the alveolar pro-
cess has important clinical impact. The obtained root po-
sition within the alveolar process was followed by
reduced gingival recessions in all patients and provided
a more favorable surgical site for a periodontal plastic
surgery to fully cover the recession.
REFERENCES
1. Karring T, Nyman S, Thilander B, Magnusson I. Bone regeneration
in orthodontically produced alveolar bone dehiscences. J Perio-
dont Res 1982;17:309-15.
2. Pazera P, Fudalej P, Katsaros C. Severe complication of a bonded
mandibular lingual retainer. Am J Orthod Dentofacial Orthop
2012;142:406-9.
3. Steiner GG, Pearson JK, Ainamo J. Changes of the marginal perio-
dontium as a result of labial tooth movement in monkeys. J Perio-
dontol 1981;52:314-20.
4. Thilander B, Nyman S, Karring T, Magnusson I. Bone regeneration
in alveolar bone dehiscences related to orthodontic tooth move-
ments. Eur J Orthod 1983;5:105-14.
5. Wainwright WM. Faciolingual tooth movement: its influence on
the root and cortical plate. Am J Orthod 1973;64:278-302.
January 2020  Vol 157  Issue 1
34
6. Wennstr€ om JL, Lindhe J, Sinclair F, Thilander B. Some periodontal
tissue reactions to orthodontic tooth movement in monkeys. J Clin
Periodontol 1987;14:121-9.
7. Engelking G, Zachrisson BU. Effects of incisor repositioning on
monkey periodontium after expansion through the cortical plate.
Am J Orthod 1982;82:23-32.
8. Nyman S, Karring T, Bergenholtz G. Bone regeneration in alveolar
bone dehiscences produced by jiggling forces. J Periodont Res
1982;17:316-22.
9. Farret MM, Farret MM, da Luz Vieira G, Assaf JH, de Lima EM. Orthodontic
treatment of a mandibular incisor fenestration resulting from a broken
retainer. Am J Orthod Dentofacial Orthop 2015;148:332-7.
10. Laursen MG, Rylev M, Melsen B. Treatment of complications after
unintentional tooth displacement by active bonded retainers.
J Clin Orthod 2016;50:290-7.
11. Machado AW, MacGinnis M, Damis L, Moon W. Spontaneous
improvement of gingival recession after correction of tooth
positioning. Am J Orthod Dentofacial Orthop 2014;145:
828-35.
12. Wennstr€ om JL. Mucogingival considerations in orthodontic treat-
ment. Semin Orthod 1996;2:46-54.
13. Miller PD Jr. A classification of marginal tissue recession. Int J Peri-
odontics Restorative Dent 1985;5:8-13.
14. Holbrook T, Ochsenbein C. Complete coverage of the denuded root
surface with a one-stage gingival graft. Int J Periodontics Restor-
ative Dent 1983;3:8-27.
15. Pini Prato G, Tinti C, Vincenzi G, Magnani C, Cortellini P, Clauser C.
Guided tissue regeneration versus mucogingival surgery in the
treatment of human buccal gingival recession. J Periodontol
1992;63:919-28.
January 2020  Vol 157  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Laursen, Rylev, and Melsen
16. Trombelli L, Schincaglia GP, Scapoli C, Calura G. Healing response
of human buccal gingival recessions treated with expanded poly-
tetrafluoroethylene membranes. A retrospective report. J Perio-
dontol 1995;66:14-22.
17. Cortellini P, Bissada NF. Mucogingival conditions in the natural
dentition: narrative review, case definitions, and diagnostic con-
siderations. J Clin Periodontol 2018;45(Suppl 20):S190-8.
18. Johal A, Katsaros C, Kiliaridis S, Leitao P, Rosa M, Sculean A, et al.
State of the science on controversial topics: orthodontic therapy
and gingival recession (a report of the Angle Society of Europe
2013 meeting). Prog Orthod 2013;14:16.
19. Leung CC, Palomo L, Griffith R, Hans MG. Accuracy and reliability
of cone-beam computed tomography for measuring alveolar bone
height and detecting bony dehiscences and fenestrations. Am J Or-
thod Dentofacial Orthop 2010;137:S109-19.
20. Patcas R, M€ uller L, Ullrich O, Peltom€aki T. Accuracy of cone-beam
computed tomography at different resolutions assessed on the
bony covering of the mandibular anterior teeth. Am J Orthod Den-
tofacial Orthop 2012;141:41-50.
21. Chambrone L, Tatakis DN. Long-term outcomes of untreated
buccal gingival recessions: A systematic review and meta-analysis.
J Periodontol 2016;87:796-808.
22. Cairo F. Periodontal plastic surgery of gingival recessions at single
and multiple teeth. Periodontol 2000 2017;75:296-316.
23. Allais D, Melsen B. Does labial movement of lower incisors influ-
ence the level of the gingival margin? A case-control study of adult
orthodontic patients. Eur J Orthod 2003;25:343-52.
24. Kerner S, Etienne D, Malet J, Mora F, Monnet-Corti V, Bouchard P.
Root coverage assessment: validity and reproducibility of an image
analysis system. J Clin Periodontol 2007;34:969-76.