3D guided comprehensive approach to

mucogingival problems in orthodontics

Marianna Evans, Nipul K. Tanna, and Chun-Hsi Chung

Advances in technology have enabled the clinician to use a 3-dimensional

(3D) guided approach to orthodontic diagnosis and treatment planning,
leading to a more predictable treatment sequence and outcome for
orthodontists and surgeons. Important factors must be taken into consid-
eration when planning orthodontic treatment such as the existing and
projected tooth position as well as the periodontal soft and hard tissue
phenotype. 3D anatomic analysis of the dentoalveolar complex may provide
more information than what can be derived from 2-dimensional radiographs
and the clinical examination. It can help identify patients at risk for the
development of mucogingival problems during or after orthodontic treat-
ment and can guide the clinician in determining the appropriate intervention
to minimize the risks of an unfavorable outcome. (Semin Orthod 2016; 22:52–
63.) & 2016 Elsevier Inc. All rights reserved.

Introduction gingival conditions include gingival recession,

absence or reduction of keratinized tissue and
stablishing periodontal health in con-
E junction with the existence of a biologically
and anatomically acceptable environment that
probing depth extending beyond the MGJ. For
the purpose of this article, attachment loss due to
periodontitis will not be discussed.
allows for the proper function and maintenance
Gingival recession is defined as an apical shift
of that health is critical for the longevity of the
of the marginal gingiva from its normal position
dentition. This requires teeth to be positioned in
on the crown of the tooth to levels on the root
the center of the alveolar housing with adequate
surface apical to the cementoenamel junction
buccolingual bone support, an adequate
(CEJ). Once developed, this condition is irre-
inflammation-free keratinized gingival seal and
versible without surgical intervention. It is critical
the presence of an occlusal scheme that allows
to note that gingival recession is simply a clinical
for even force dissipation in an axial direction,
manifestation of an underlying alveolar bone
free of interferences.
problem. It is always accompanied by alveolar
Patients with a malocclusion may present with
bone dehiscences of varying degrees. Löst,2 in a
pre-existing mucogingival problems or fragile
human study on correlation between gingival
periodontal support that is susceptible to
recession and alveolar bone dehiscences, found a
attachment loss during or after orthodontic
minimal distance of around 3 mm between the
treatment. The American Academy of Perio-
vestibular gingival margin and the alveolar bone
dontology (AAP) defines mucogingival con-
margin of teeth affected by gingival recession.
ditions as deviations from the normal anatomic
Alveolar bone dehiscence may be present
relationship between the gingival margin and the
without manifestation of gingival recession, but
mucogingival junction (MGJ).1 Common muco-
gingival recession cannot develop without simul-
taneously manifesting or pre-existing bone loss.2
Department of Orthodontics, School of Dental Medicine, Uni- According to Loe et al.,3 gingival recession
versity of Pennsylvania, Pennsylvania, PA. begins early in life and is found primarily on the
Address correspondence to Marianna Evans, DMD, Department
labial root surfaces. Prevalence varies from 3% to
of Orthodontics, School of Dental Medicine, University of Pennsylva-
nia, Philadelphia, PA. E-mail: mevans@infinityorthoperio.com
100% depending on the population and the
& 2016 Elsevier Inc. All rights reserved.
methods of analysis, and appears to be lower in
1073-8746/12/1801-$30.00/0 younger groups, where the incidence increases
http://dx.doi.org/10.1053/j.sodo.2015.10.008 with age.4 If left untreated, it may result in the

Seminars in Orthodontics, Vol 22, No 1, 2016: pp 52–63 52

 3D guided comprehensive approach to mucogingival problems in orthodontics 53

loss of the tooth, followed by further resorption To prevent or address gingival recession in sus-
of the underlying bone. ceptible patients, predictable soft tissue grafting
The etiology of recession is multi-factorial5 procedures such as the subepithelial connective
and may include bacterial plaque, tooth brush tissue graft (SCTG) and the free gingival graft
and toothpaste abrasion, occlusal trauma, oral (FGG) may be performed prior to or after tooth
piercing, iatrogenic factors related to restorative movement.14,15 Since gingival recession is also a
and periodontal therapy, tooth position/tooth bone problem, hard tissue grafting procedures to
size in relation to the surrounding bone volume, thicken the buccolingual alveolar bone dimen-
orthodontic malocclusion, gingival biotype and sion may be beneficial in selected cases.
high frenum attachment. Alveolar bone deficiency is a common finding
Gingival recession may develop or progress in the general population.16 Before cone-beam
before, during or after orthodontic treatment. computed tomography (CBCT) technology, the
The correlation between orthodontic tooth alternative to diagnosing buccolingual alveolar
movement and attachment loss remains con- bone dimension without flap reflection was to
troversial due to the lack of randomized con- use costly, medical CT scans that were associated
trolled studies.6,7 In spite of that, it has been with much higher radiation. Traditionally, 2-
reported that the buccolingual tooth position dimensional images such as lateral cephalograms
and movement will affect the thickness and width have been used to evaluate changes in the incisor
of keratinized gingiva.8,9 Teeth positioned more inclination. These images are limited to evalua-
lingually will often have a wider band of kerati- tion of the average buccolingual incisor position
nized gingiva than those positioned more labi- in relationship to large anatomic landmarks such
ally. This phenomenon may be explained by as mandibular plane or the A-Pog line and lack
spatial redistribution of the gingival tissue in a precise visibility of the anatomy of the symphysis
buccolingual dimension during tooth move- and position in the bone of each individual
ment. Multiple studies also confirm that thin tooth.17 Often, mandibular incisors that are
gingival biotype and the presence of alveolar positioned within the normal range of 851–951
bone dehiscences predispose patients to gingival to the mandibular plane present with significant
recession with or without orthodontic tooth variations with respect to their position within the
movement.10–12 Wennstrom et al.13 evaluated the symphysis and with different amounts of
periodontal reaction to orthodontic movement supporting bone. This variation can only be
in monkeys and reported that plaque-induced identified with 3D images (Fig. 1).
inflammation and the thickness (volume) of CBCT imaging allows for an additional per-
the marginal soft tissue, rather than the spective into understanding how mucogingival
apico-coronal width of the keratinized and problems relate to orthodontic tooth movement
attached gingiva, are determining factors for the by allowing us to differentiate whether the
development of gingival recession and attach- problem lies in the tooth position, the anatomy of
ment loss during orthodontic tooth movement. the surrounding bone, or both (Fig. 2). A weak

Figure 1. CBCT images of lower incisors (from different patients) positioned within 851–951 to the mandibular
plane but with a diverse positioning within the symphysis and with differing amounts of alveolar bone support.
54 Evans et al

Figure 2. CBCT images of mandibular incisors with recession (tooth 24) from 2 different patients. (A) The lower
incisor is centered in the symphysis but presents with an alveolar bone deficiency on the labial. (B) The mandibular
incisor is positioned labial in relationship to the symphysis.

correlation has been reported between gingival a scan based on these factors. According to Patcas
thickness and underlying bone thickness, et al.,21 even the 0.125-mm voxel protocol does
although a positive correlation has been identi- not depict the thin buccal alveolar bone covering
fied between crestal alveolar bone thickness and reliably, and there is a risk of overestimating
width of the gingiva.18 Cook et al.19 reported that fenestrations and dehiscences. In a recent study
thin gingival biotype was associated with thinner by Sun et al.22 similar findings were reported with
labial plate thickness. It should be noted that CBCT images having some diagnostic value for
patients with a thick, wide band of keratinized detecting bony dehiscences and fenestrations;
gingiva may present with deficient alveolar bone. however, this method might overestimate the
Mandelaris et al.20 suggested that when studying actual measurements.
alveolar bone with CBCT, one must differentiate
between the crestal and radicular zones of
Buccolingual alveolar bone dimension
alveolar bone. The dentoalveolar crestal zone is
defined as the region from the CEJ to a point In the ideal situation, the tooth is positioned in
4-mm apically and the dentoalveolar radicular the center of the alveolus, to receive axial loading
zone is dependent upon the individual root with bone covering the root circumferentially 1–
length and is that area extending below the 4-mm 2 mm below the CEJ with at least 1 mm of bone
line for the remaining root length. Both crestal thickness on the labial and lingual surfaces of the
and radicular bone can be identified as thick root. We suggest evaluating the buccolingual
(41 mm) or thin (o1 mm). Patients also may (BL) alveolar and basal bone dimension in
present with different combinations of alveolar relationship to individual buccolingual root
bone thickness in both zones.20 dimension. In the optimal environment, when
the tooth is centered in alveolar bone, the BL
bone dimension should be at minimum 2-mm
3D guided evaluation of the dentoalveolar
wider than the root dimension at any given root
complex
cross-section (Type A) to allow minimal root
Advances in CBCT imaging technology and coverage within alveolar bone of 1 mm in
developments in 3D simulation software allow us thickness on both labial and lingual surfaces of
to evaluate not only pretreatment dentoalveolar the root (Fig. 3A). Anything less should be
anatomy but also the projected tooth movement considered as compromised (Type B) and will
and its relationship relative to the alveolar bone. present a risk for the development of gingival
While the additional information gained provides recession (Fig. 3B). Type B alveolar bone may be
a new perspective, it also brings with it many subdivided into Type B-1 (thin alveolar plate less
unanswered questions which will require ongoing than 1 mm in thickness), Type B-2 (fenestration)
research with randomized controlled studies. and Type B-3 (dehiscence) and is found either
Many factors such as variations in equipment, on the labial, lingual or both root surfaces. Teeth
settings, field of view, voxel size etc., play a critical with dehiscences (Type B-3) and thin overlying
role in the accuracy of the images. Thin labial gingiva are the most susceptible to gingival
plates, for example, may or may not be evident on recession.
 3D guided comprehensive approach to mucogingival problems in orthodontics 55

Figure 3. (A). Type A: A—Optimal buccolingual alveolar bone dimension of the anterior teeth. B—Posterior
teeth. C—Example of Type A bone as shown on a CBCT coronal slice at the first molar. (B) Type B: A,B—
Compromised buccolingual alveolar bone dimension of the anterior and posterior teeth. C—Example of Type B
bone as shown on a CBCT coronal slice at the first molar.

Tooth position position has been addressed. However, in most

situations this improvement is not possible with
CBCT examination of the dentoalveolar complex
orthodontic tooth movement alone.
also includes evaluation of the pretreatment and
A more common clinical scenario is when the
projected spatial position of the tooth within tooth movement may result in a situation with
bone. In some situations, the tooth might be more compromised soft tissue and bone sup-
positioned off-axis and present radiographically port.24 With advances in 3D software, the
with fenestrations and dehiscences with sufficient majority of the tooth movement can be
quantity of surrounding bone to support it in simulated before treatment begins. Fig 5
proper position (Fig. 4A). In these situations, the illustrates possible projected tipping and bodily
determination needs to be made whether movements of the mandibular incisor from the
anticipated orthodontic treatment will improve original optimal position (A) in the center of the
tooth position in the bone or not. In some ridge and the effects on the alveolar bone. Image
situations, positioning the tooth in the center of B, for example, shows that significant labial
the alveolar bone may improve dehiscences and tipping will not compromise the alveolar
fenestrations and even possibly gingival housing, while lingual tipping (C), labial bodily
recession23 (Fig. 4B). If that improvement is movement (D), and combination of lingual
feasible, many mucogingival and alveolar bone tipping and labial root movement (E), will
deficiencies can be re-evaluated after the tooth compromise alveolar bone support.

Figure 4. (A) Retroclined lower incisor with severe labial dehiscence related to labial root position. (B) The same tooth
after orthodontic movement into the center of the symphysis presents with improved labial alveolar bone support.
56 Evans et al

Figure 5. Projected tooth movement with alveolar bone implications. (A) Optimal tooth position in the symphysis
with optimal labial and lingual alveolar bone support. (B) Labial tipping with no effects on the alveolar bone
support. (C) Lingual tipping with thinning of the labial alveolar bone. (D) Labial bodily movement with an
anticipated development of a labial dehiscence. (E) Lingual crown tipping and labial root torque outside the
symphysis with the anticipated development of a severe labial dehiscence.

By studying dentoalveolar anatomy in 3D at gingival bleeding index, thickness and width of

the individual tooth level, we may be able to the attached and keratinized gingiva and frenum
better identify patients at risk of developing anatomy. Conventional periapical radiographs
mucogingival problems and also to understand reveal the interproximal bone level, presence
the underlying anatomy of the existing muco- of a lamina dura and root length, but are
gingival deformities. limited in the evaluation of the buccolingual
dentoalveolar anatomy. 3D imaging provides
additional information to assess the buccolingual
Pre-orthodontic comprehensive 3D guided
anatomy, and when combined with the clinical
periodontal evaluation
exam, will serve as a guide to identify patients with
Patients with malocclusion often present for anatomic risk factors for attachment loss prior to
orthodontic treatment with periodontal mani- initiating tooth movement.
festations of varying degrees, thin gingival bio- When identifying mucogingival problems and
type and deficient alveolar bone support.25,26 potential risks of developing them in orthodontic
A comprehensive periodontal evaluation is patients, 3 scenarios may be identified:
essential for all adult patients and when indi-
cated, for selective adolescent patients with thin (1) Pre-existing mucogingival conditions: When
periodontium. patients present for orthodontic treatment
The presence of orthodontic appliances makes with gingival recession, with or without lack
oral care challenging and may present a risk for of attached gingiva and high frenum
the development of plaque-induced gingival attachment.
inflammation.27 Additionally, some types of (2) Pre-existing risks: When patients present
orthodontic tooth movement may position the with Type B buccolingual alveolar bone
teeth outside the envelope of periodontal support. dimension accompanied by thin or thick
The clinical periodontal evaluation includes gingiva without clinical manifestations of
measurements of sulcular probing depth, mucogingival problems.
 3D guided comprehensive approach to mucogingival problems in orthodontics 57

(3) Projected risks: When the anticipated tooth attachment loss, periodontal augmentation pro-
movement is predisposed to the develop- cedures should be considered.
ment of dehiscences, fenestrations and gin- Augmentation may include manipulation
gival recession. within the soft tissue, the hard tissue, or a com-
bination of both based on the clinical and
First and foremost, educating patients in radiographic findings and the treatment plan.
proper oral hygiene is fundamental to prevent Therapeutic grafting is indicated in patients with
attachment loss during and after orthodontic pre-existing mucogingival conditions, while
treatment. prophylactic grafting is performed in situations
With pre-existing mucogingival conditions, of pre-existing or projected risks.
grafting should be considered when there is a When performing periodontal augmentation
risk for the progression of attachment loss during surgery, oral hygiene is critical to optimal heal-
or after tooth movement. This is usually related ing. Gingival inflammation related to poor oral
to compromised oral hygiene, labial tooth care will compromise healing and presents
movement and lack of attached gingiva. When challenges to diagnose the true periodontal
the patient has a wide band of keratinized tissue, condition of the marginal gingival tissue. Place-
free of inflammation and the anticipated tooth ment of orthodontic appliances should be
movement will not exceed beyond the bone delayed until after soft tissue healing takes place
support, root coverage may be postponed until (4-6 weeks post-surgery) when the patient
after orthodontic treatment. resumes a regular oral hygiene regimen.
When evaluating patients at risk for develop-
ing attachment loss during or after orthodontic
treatment, initial identification of the tooth Soft tissue augmentation
position is critical. Teeth positioned outside of Pre-orthodontic soft tissue augmentation is
bone support and in traumatic occlusal rela- performed to address existing mucogingival
tionships may significantly contribute to exacer- deformities (i.e., gingival recession) (Fig. 7)
bation of mucogingival problems. Therefore, as well as to convert a patient from a thin
positioning them back into bone and relieving gingival biotype to a biotype less susceptible
occlusal trauma should precede surgical inter- to periodontal breakdown during tooth
vention. In some instances, a mucogingival movement (Fig. 8). Autogenous free gingival
problem will improve after occlusal trauma is and subepithelial connective tissue grafts as well
eliminated and surgical intervention may be as skin allografts have been successfully used for
avoided (Fig. 6). gingival augmentation.28,29 Autogenous soft tis-
sue grafting procedures require a thorough
understanding of the anatomic relationships to
Pre-orthodontic periodontal augmentation vital structures in recipient and donor sites. Free
Once it has been determined that orthodontic gingival grafts may be harvested from palatal
tooth movement will present a risk for and buccal areas, depending on the required

Figure 6. (A) A 7-year-old male patient presents with an anterior crossbite and crowding with lack of
attached gingiva on tooth 24. (B) 6 Months after addressing the anterior crossbite and improving the lower
incisor crowding, tooth 24 presents with a sufficient band of keratinized gingiva without the need for
surgical intervention.
58 Evans et al

Figure 7. (A) Gingival recession on tooth 22 with no attached keratinized gingiva. (B) A SCTG
was performed prior to tooth movement to address the recession and create keratinized attached gingiva.
(C) Complete root coverage was achieved with a 2 mm band of keratinized attached gingiva at 1 month post-
surgery.

graft size, thickness and quantity of available recipient and donor sites due to thinner grafts,
donor tissue. improves patient comfort, prevents reattach-
A recently held AAP Regeneration Workshop ment of the frenum and allows for better
(2015) concluded that in optimal plaque-control graft blending with the surrounding gingiva
conditions, in the absence of inflammation, (Fig. 9).
there is no need for a minimal width of kerati- Since gingival recession is an alveolar bone
nized gingiva to prevent attachment loss. How- problem, hard tissue grafting may also have to
ever, in situations when plaque control is be considered in addition to the soft tissue
suboptimal as during orthodontic treatment, a augmentation. In these situations, it might be
minimum width of 2 mm of keratinized tissue beneficial to combine a connective tissue graft
with 1 mm of attached gingiva is required.29 This with bone augmentation, which will be discussed
workshop recommended the FGG as a standard later in this article.
for the gain of keratinized gingiva, although the
free connective tissue graft (FCTG) may also
fulfill this purpose.28
Hard tissue augmentation
Considering all treatment modalities in It is worth noting that the concept of surgical
periodontal plastic surgery to create an ade- manipulation of the alveolar ridge facilitating
quate band of attached keratinized gingiva, the tooth movement dates back to Kole30 in
most optimal indication for the FGG procedure 1959. Suya31 specifically reported corticotomy
today in orthodontic patients is when it is facilitated orthodontics in 1991. Findings from
performed in conjunction with a frenectomy. this work lead Wilcko et al.32 to explore the
FGGs that are performed in conjunction with a concept further. While additional randomized
frenectomy are usually smaller in size and controlled trials are still needed to understand
almost always may be harvested from the buccal. this process and to substantiate certain
This allows for expedited healing of the claims, initial case reports have shown stable

Figure 8. (A) An 11-year-old Caucasian male patient presents for orthodontic treatment with severe lower
crowding, thin gingival tissue with no attached gingiva on tooth 25. (B) SCTG procedure was performed on the
lower incisors to thicken the gingiva in order to prevent attachment loss during tooth movement. (C) 6 Months
after grafting, lower incisors were aligned and presented with a thick band of coronaly positioned keratinized
gingiva.
 3D guided comprehensive approach to mucogingival problems in orthodontics 59

Figure 9. (A) A 15-year old AA female presents for orthodontic treatment with thin labial gingiva and a high
frenum attachment at the level of the mandibular central incisors. (B) Prior to orthodontic tooth movement, a
FGG was harvested from the buccal gingiva between the maxillary right premolar and canine. (C and D)
Transplantation to the frenectomy site with the purpose of widening the zone of keratinized gingiva and
preventing re-attachment of the frenum. Buccal donor tissue was used for the sake of patient comfort. (E) 1-year
post-treatment, mandibular incisors present with a healthy band of keratinized gingiva without signs of
attachment loss.

results with a significant decrease in the time of bone may prevent gingival recession, while
treatment.32 In addition to the benefit of augmentation in the radicular zone may
a decrease in treatment time, the use of prevent root movement outside the alveolar
bone grafting materials, acting as scaffolding bone dimension and increase stability of the
for additional bone formation, has been achieved tooth alignment.
explored further to increase the envelope of Although decrease in treatment time35 and
tooth movement and still provide a stable post-orthodontic stability36 have been reported
periodontal outcome. Previous studies5,33,34 in the literature as a result of this procedure, the
have reported cases in which orthodontic cor- effectiveness of bone augmentation has yet to be
rections were achieved with movement into sites investigated.
that would normally have been considered
periodontally unhealthy if they had been com-
pleted using conventional methods without
Combined hard and soft tissue augmentation
surgical intervention.
Bone augmentation is beneficial for ortho- When the clinical and radiographic exam
dontic patients with Type B alveolar anatomy, in reveals an underlying or projected soft and
particular when non-extraction therapy is elected hard tissue deficiency as shown in Fig 12,
for airway and esthetic considerations (Fig. 10). combined soft and hard tissue augmentation
Studying the pre-existing and projected den- may be the treatment of choice. Subepithelial
toalveolar anatomy will aid in the decision- connective tissue grafting may be done
making of whether bone grafting can be lim- simultaneously with bone grafting or in a
ited to the labial area or extended to the labial stepped approach. When soft tissue augmen-
and lingual root surfaces (Fig. 11). Anatomic tation involves multiple teeth, a soft tissue
limits also have to be considered with respect to allograft might be the material of choice as
graft containment. Augmentation of the crestal shown in Fig. 13.
60 Evans et al

Figure 10. (A and B) A 21-year-old Caucasian male presents for orthodontic re-treatment with upper and lower
crowding, thin gingival biotype and Type B alveolar bone on the mandibular anterior teeth. (C–G) Labial bone
augmentation of the lower anterior teeth was completed with corticotomy and grafted with particulate freeze-
dried bone allograft material. (H) CBCT sagittal slice of the post-treatment augmented labial alveolar bone with
3-mm increase in thickness at the level of lower incisor. (I) Final records taken 3 months after debond show
thickening of the labial gingiva after orthodontic alignment in conjunction with prophylactic labial bone
augmentation. (J) 3D image of the pretreatment airway with constriction in the retroglossal area of 83.2 mm2.
(K) 3D image of the post-treatment airway with increase of the airway volume in the retroglossal area to 188 mm2.
 3D guided comprehensive approach to mucogingival problems in orthodontics 61

Figure 11. (A and B) labial, (C and D) labial and lingual bone augmentation (blue dotted line) based on CBCT
findings of alveolar bone deficiency.

Figure 12. (A and B) A 28-year-old female patient presents for non-extraction orthodontic treatment with severe
crowding, thin gingival biotype and deficient Type B bone support on the labial of lower anterior teeth. (C–F) A
combination of labial soft and hard tissue augmentation was performed with subepithelial connective tissue graft in
conjunction with freeze dried bone allograft and xenograft mixture prior to tooth movement.
62 Evans et al

Figure 13. (A–C) Combined soft tissue and hard tissue augmentation with an acellular dermal matrix and freeze-
dried bone allografts performed on a 39-year-old female patient with thin gingiva and Type B alveolar bone.

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