Interventional Medicine & Applied Science, Vol.

10 (2018) ORIGINAL PAPER

Risk factors contributing to gingival recession

among patients undergoing different
orthodontic treatment modalities
NOZHA MAHMOUD SAWAN1,*, AHMED GHONEIMA2, KELTON STEWART2, SEAN LIU3

1
Department of Preventive Dental Sciences, College of Dentistry, Princess Nourah Bint Abdulrahman University, Riyadh,
Kingdom of Saudi Arabia
2
Department of Orthodontic and Oral Facial Genetics, Indiana University School of Dentistry, Indianapolis, IN, USA
3
Private Practice, Kent, WA, USA
*Corresponding author: Nozha Mahmoud Sawan, BDS, MED; Department of Preventive Dental Sciences, College of Dentistry,
Princess Nourah Bint Abdulrahman University, 7396 Wadi As Saws, An Nahdah, Riyadh 3804 13222, Kingdom of Saudi Arabia;
Phone: +966 5390 88 892; E-mail: [email protected]

(Received: November 4, 2017; Revised manuscript received: November 27, 2017; Accepted: November 29, 2017)

Abstract: Objective: The aim of this study was to investigate the risk factors contributing to gingival recession among patients undergoing orthodontic
treatment. Methods: Records of 100 Caucasian patients who completed orthodontic treatment were evaluated before and after treatment. Intercanine
and molar widths, arch perimeter, arch depth, and keratinized gingival height were measured for both arches. The association of orthodontic
treatment strategy (changing incisal inclination, expansion, and extraction), keratinized gingival height, and various other measurements with gingival
recession was evaluated by using generalized linear mixed models with logistic regression analysis. Results: For each 1 mm increase in
pre- and post-treatment keratinized gingival height, there was 0.77 and 0.51 times lower odds of gingival recession. For each 1 mm increase in
post-treatment intercanine width, there was 0.80 times lower odds of gingival recession. And for each 1 mm increase in change in the arch depth,
there was 1.16 times higher odds of gingival recession. For each 1 mm increase in pre- and post-treatment mandibular symphysis width, there was
0.47 and 0.39 times lower odds of gingival recession. Conclusion: Regardless of the type of orthodontic treatment, increased keratinized gingival
height, mandibular symphysis width, and post-treatment intercanine width lower the risk of gingival recession.

Keywords: gingival recession, orthodontic treatment, keratinized gingiva, extraction, odds ratio

Introduction factors such as traumatic tooth brushing and bruxism are

suggested to initiate or worsen gingival recession [9].
Gingival recession is defined as the apical displacement of (5) Periodontal conditions such as decreased keratinized
the marginal gingiva relative to the cementoenamel junc- gingival thickness and height, reduced alveolar bone thick-
tion (CEJ) that results in root caries, hypersensitivity, and ness as a result of tooth malposition, tapered tooth shape,
unaesthetic appearance [1, 2]. Multiple factors are consid- and presence of dehiscence/fenestration are also common
ered to contribute to gingival recession. (1) Age-related risk factors for gingival recession [10–12].
gingival recession is more prevalent in individuals older Orthodontic treatment is considered to be an iatro-
than 50 years [3, 4] without gender preference [5–7]. (2) genic factor that contributes to gingival recession [11, 13,
Population-related gingival recession occurs more in Cau- 14]. Although a well-aligned dentition is favorable for
casians [3, 4] and in populations without access to dental maintaining periodontal health [12], recent systematic
care [3]. (3) Site-related gingival recession is observed reviews support the association between orthodontic
more frequently on the facial surfaces of mandibular central treatment and gingival recession [11, 14, 15]. The move-
incisors and maxillary first molars [8]. (4) Mechanical ment of teeth with thin tissue biotype has been previously

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DOI: 10.1556/1646.9.2017.42 1 ISSN 2061-1617 © 2018 The Author(s)

 Sawan et al.

investigated using a primate model, demonstrating that

extensive bodily movement of teeth resulted in alveolar
bone height reduction and an apical displacement of
gingiva [13]. This occurs with flaring of incisors to resolve
crowding, expansion of dental arches to correct transverse
discrepancies, or retraction of anterior teeth to close
extraction spaces. Predisposing factors of gingival reces-
sion in orthodontic patients are still not clear. Associa-
tions between what is thought to be predisposing factors
such as age, gender, keratinized gingival height and the
different orthodontic treatment modalities (extraction,
changing incisal inclination, and (or) changing interca-
Fig. 1. Scoring the presence of gingival recession (Y: yes; N: no)
nine and -molar widths) have not been investigated.
With this background, the aim of this study was to
investigate the risk factors contributing to gingival reces-
sion among patients undergoing orthodontic treatment. (maxillary and mandibular, canine to canine). Gingival
recession was recorded as nominal data, denoted as either
yes or no. Recession was scored as “Yes” if the labial CEJ
Materials and Methods is exposed. Other cast analyses (Fig. 2) were based on
standardized occlusal scans for maxillary and mandibular
Participants
dental models. A color scanner (Aficio MP 3351, Ricoh
Americas Corporation, Malvern, PA) with a resolution of
The post-treatment archive at a graduate orthodontic
600 dpi was used to obtain standardized scans of the
program in a university setting was searched to identify
occlusal aspect of each model. The following measure-
patients who received full comprehensive orthodontic
ments were computed from the scanned maxillary and
treatment. Patients who are Caucasian and started ortho-
mandibular casts: (1) arch depth (Fig. 2a): the distance
dontic treatment with full permanent dentition (from first
from a point midway between the palatal surfaces of the
molar to first molar in both arches) with complete pre-
central incisors at the embrasure to a perpendicular line
and post-orthodontic treatment records (orthodontic
drawn from the mesial aspect of the permanent first
models, intra-oral photographs, and cephalometric radio-
molars [16]; (2) intercanine width (Fig. 2b): the distance
graphs) were included. Exclusion criteria included patients
between canine cusp tips; (3) intermolar width (Fig. 2b):
>50 years old, cigarette smokers, and patient with systemic
the distance between lingual grooves of maxillary first
diseases that affect periodontium (e.g., diabetes and oste-
molar, and the distance between central fossae of man-
oporosis), craniofacial anomalies, orthognathic or peri-
dibular first molar [16]; (4) arch perimeter (Fig. 2c): the
odontal surgery, gingival recession prior to orthodontic
sum of the distances from the mesial contact points of
treatment, plaque accumulation, and gingival inflamma-
the permanent first molars to the distal contact points of
tion before treatment and at the time of debonding.
the canines plus the distances from the distal contact
A total of 100 Caucasian patients who were debonded
points of the canines to the mesial contact points of the
between 2012 and 2014 were consecutively selected (F:
central incisors [16]; (5) crowding or spacing (Fig. 2d):
n = 77, M: n = 23). Pre- (T1) and post-treatment (T2)
the sum of mesiodistal widths of all teeth mesial to
records (dental casts, intra-oral photographs, and cepha-
the first molar to the mesial surface of the opposite
lomteric radiographs) were evaluated. A time frame of
first molar will be subtracted from arch perimeter. Posi-
1–3 years was set for treatment to include patients who
tive or negative results indicated spacing or crowding,
were treated between 1 and 3 years. Patient data were
respectively.
deidentified by the primary investigator and no link
All measurements were performed by one trained and
between collected data and charts was maintained.
calibrated investigator (NMS) using a software program
Patients were categorized into three groups; those who
(Dolphin® Imaging 11.5 Premium, Dolphin Imaging &
underwent extraction (n = 25), those who had more than
Management Solutions, Chatsworth, CA, USA).
5° change in incisal angle (n = 43), and those who
underwent arch expansion (n = 32). Patients’ age ranged
from 12 to 26 years, with a mean age of 13.5 years. Intra-oral photos assessment

Cast measurements Keratinized gingival height was assessed at the mid buccal
aspect of each maxillary and mandibular anterior tooth
The plaster models from (T2) (Fig. 1) were evaluated for (canine to canine) from intra-oral photos (Fig. 3). These
the presence of gingival recession for each anterior tooth intra-oral colored photographs were taken with a digital

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 Gingival recession after orthodontic therapy

Fig. 2. Cast measurements. (a) Arch width is determined by the distance from a point midway between the labial surfaces of the central incisors at
the embrasure to a perpendicular line drawn from the mesial aspect of the permanent first molars. (b) Intercanine width (ICW) is
determined by measuring the distance between the canine cusp tips. Intermolar width (IMW) is determined by measuring the distance
between central fossae of the first molars. (c) Arch perimeter is determined by measuring the distance from the mesial contact points of the
permanent first molars to the distal points of the canines to the mesial contact points of the central incisors. (d) Crowding and spacing
were measured by subtracting the sum of mesio-distal widths of all teeth mesial to the 1st permanent molar to the mesial of the opposite
1st molar

camera (EOS, REBEL XTi, Canon® Global, Tokyo, the upper incisors and Sella–Nasion line; U1/SN) and
Japan). The length and focal length of the lens were EF the mandibular incisal inclination (the angle formed
100 mm and 2.8 Macro, respectively. The images were by the lower incisor teeth and the mandibular plane;
obtained at the following settings: Flash ETTL, F-stop @ L1/MP) were measured. In addition, the mandibular
32, shutter speed @ 1/60, and ISO @ 200. Each frontal symphysis width was measured as the shortest distance
and lateral intra-oral photograph was viewed using Dol- between the anterior and posterior borders of the
phin software. First, each crown length was measured on symphysis (Fig. 4).
the cast using an electronic caliper “Pittsburgh6’ Digital
Caliper” with an accuracy of 0.01 mm. Second, each Intra-examiner reliability
crown length was calibrated in intra-oral photo using
Dolphin® Imaging 11.5 Premium. The height of kerati- A single calibrated and trained investigator (NMS) iden-
nized gingiva was measured in intra-oral photograph tified landmarks and conducted measurements. Twenty
using Dolphin® Imaging 11.5 Premium. patients were randomly selected and all measurements
were repeated after 2 weeks. The intra-examiner reliabili-
Cephalometric analysis ty was confirmed with the intra-class correlation coeffi-
cients ranging from 1 to 0.98 for cast and cephalogram
To measure the change in incisal inclination from T1 to measurements, and from 1 to 0.93 for intra-oral photo-
T2, the maxillary incisal inclination (the angle formed by graph measurements.

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 Sawan et al.

Results
Summary of mean and standard errors of each predictor is
listed in Table I. The predictors were evaluated using
backward selection, until all predictors remaining in the
model were significant (P < 0.05). None of the different
orthodontic treatment strategies were found significant
(P = 0.058). As a model, pre-treatment keratinized gin-
gival height (P < 0.01), post-treatment keratinized gingi-
val height (P < 0.001), post-treatment intercanine width
(P < 0.0001), and change in arch depth (P < 0.05) were
found to be statistically significant to gingival recession
(Table II). For each 1 mm increase in pre-treatment
keratinized gingival height, there was 0.77 times lower
odds of gingival recession. For each 1 mm increase in
post-treatment keratinized gingival height, there was
0.51 times lower odds of gingival recession. For each
1 mm increase in post-treatment intercanine width, there
was 0.80 times lower odds of gingival recession and for
each 1 mm increase in change in arch depth, there was
1.16 times higher odds of gingival recession (Table II).
An additional model was created by adding the non-
extraction variable into the model. Non-extraction treat-
ment gave 1.31 times higher odds of gingival recession
(Table III).
Two final models were created for pre- and post-
treatment mandibular symphysis widths as they were
statistically significant predictors of gingival recession
(P < 0.001) (Tables IV and V). For each 1 mm increase
in pre-treatment mandibular symphysis width, there was
0.47 times lower odds of gingival recession (Table IV)
and for each 1 mm increase in post-treatment mandibular
symphysis width, there was 0.39 times lower odds of
gingival recession (Table V).
Predictors specific to upper and lower incisal inclina-
Fig. 3. Pre-orthodontic intra-oral photos showing the keratinized
gingival height measurements tion were evaluated separately. None of the variables were
statistically significant to gingival recession (change in
U1/SN P = 0.6, change in L1/MP P = 0.5).

Statistical analysis Discussion

Power analysis was performed prior to any evaluation. Gingival recession following orthodontic treatment has
With a sample size of 100 patients, the study has 80% been a debatable topic throughout the years. In this study,
power to detect an odds ratio of 2.5 for predictors that 87% of the patients demonstrated gingival recession on at
are continuous measurements and odds ratio of 4.5 for least one of the upper or lower anterior teeth after ortho-
predictors that are categorical variables with prevalence dontic expansion, or extraction that had no association
of 25%, assuming two-sided tests conducted at a 5% with gingival recession. However, backward selection
significance level and the percentage of patients with at model showed that treatment with non-extraction case
least one recession is 10%. The association of ortho- tends to increase the level of gingival recession.
dontic treatment modality (changing incisal inclina- Historically, the position of mandibular incisors has
tion, arch expansion, or extraction), keratinized been considered the key for achieving good facial aes-
gingival height, patient’s age, and patient’s gender thetics [17–21]. A recent systematic review concluded
with gingival recession was evaluated by using general- that although there is an association between incisor
ized linear mixed models with logistic regression inclination and gingival recession, the severity of gingival
analysis. recession cannot be considered clinically significant [11].

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 Gingival recession after orthodontic therapy

Fig. 4. Cephalogram measurements. (a) Maxillary incisal inclination: angle formed by Sella–Nasion and maxillary incisal planes. (b) Mandibular
incisal inclination: angle formed by Menton–Gonion and mandibular incisors planes. (c) Mandibular symphysis width measured as the
distance between the anterior border and the posterior border of the symphysis

Table I Means (standard errors) for predictors of gingival recession (by extraction status)

Gingival
Predictor Extraction recession Pre-treatment Post-treatment Change (post–pre)
Age No No 13.77 years (0.10) N/A N/A
Yes 13.72 years (0.12) N/A N/A
Yes No 14.27 years (0.15) N/A N/A
Yes 14.17 years (0.21) N/A N/A
Keratinized gingival height No No 3.30 mm (0.05) 3.05 mm (0.05) −0.26 mm (0.03)
Yes 2.13 mm (0.07) 1.76 mm (0.06) −0.37 mm (0.06)
Yes No 3.29 mm (0.10) 3.02 mm (0.10) −0.27 mm (0.08)
Yes 1.82 mm (0.12) 1.64 mm (0.09) −0.18 mm (0.08)
Intercanine width No No 30.75 mm (0.18) 31.97 mm (0.17) 1.22 mm (0.08)
Yes 26.78 mm (0.20) 27.98 mm (0.19) 1.20 mm (0.07)
Yes No 30.65 mm (0.43) 32.71 mm (0.29) 2.06 mm (0.40)
(Continued)

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Table I (Continued)
Gingival
Predictor Extraction recession Pre-treatment Post-treatment Change (post–pre)
Yes 26.85 mm (0.36) 28.19 mm (0.34) 1.33 mm (0.24)
Intermolar width No No 36.36 mm (0.17) 37.28 mm (0.19) 0.92 mm (0.08)
Yes 39.12 mm (0.20) 40.34 mm (0.18) 1.22 mm (0.10)
Yes No 35.71 mm (0.28) 36.01 mm (0.28) 0.29 mm (0.15)
Yes 38.82 mm (0.39) 39.07 mm (0.37) 0.25 mm (0.31)
Lower incisors to No No 90.44° (0.62) 94.17° (0.57) 3.73° (0.38)
mandibular plane angle Yes 90.34° (0.40) 94.35° (0.40) 4.01° (0.32)
Yes No 91.18° (0.99) 91.46° (0.70) 0.28° (1.00)
Yes 92.69° (0.97) 93.32° (0.93) 0.63° (0.83)
Mandibular symphysis No No 6.09 mm (0.07) 5.44 mm (0.08) −0.65 mm (0.05)
width Yes 5.63 mm (0.04) 4.87 mm (0.05) −0.76 mm (0.03)
Yes No 6.58 mm (0.14) 5.67 mm (0.12) −0.91 mm (0.09)
Yes 6.22 mm (0.10) 4.99 mm (0.10) −1.23 mm (0.11)
Arch perimeter No No 68.99 mm (0.25) 70.11 mm (0.26) 1.12 mm (0.14)
Yes 63.85 mm (0.30) 65.08 mm (0.30) 1.23 mm (0.20)
Yes No 69.15 mm (0.45) 62.02 mm (0.48) −7.13 mm (0.45)
Yes 64.47 mm (0.54) 56.81 mm (0.74) −7.67 mm (0.73)
Upper incisors to Sella– No No 100.57° (0.47) 104.82° (0.35) 4.25° (0.39)
Nasion plane angle Yes 99.15° (0.70) 103.38° (0.58) 4.23° (0.65)
Yes No 104.39° (0.64) 105.40° (0.59) 1.01° (0.84)
Yes 99.57° (2.24) 105.10° (2.01) 5.53° (3.87)
Spacing crowding No No −1.80 mm (0.15) N/A N/A
Yes −3.03 mm (0.17) N/A N/A
Yes No −5.67 mm (0.38) N/A N/A
Yes −6.08 mm (0.49) N/A N/A
Arch depth No No 23.51 mm (0.11) 22.88 mm (0.11) −0.62 mm (0.07)
Yes 21.31 mm (0.13) 21.20 mm (0.14) −0.12 mm (0.10)
Yes No 23.47 mm (0.22) 19.53 mm (0.23) −3.93 mm (0.24)
Yes 21.35 mm (0.26) 17.42 mm (0.30) −3.93 mm (0.32)

Table II Best predictors of gingival recession using backward selection

Effect Estimate Exponentiated estimate SE DF t P value

Intercept 8.68 0.87 99 9.94 <0.0001
Pre-treatment keratinized gingival height −0.26 0.77 0.10 1,096 −2.60 0.0094
Post-treatment keratinized gingival height −0.68 0.51 0.13 1,096 −5.05 <0.0001
Post-treatment intercanine width −0.23 0.80 0.03 1,096 −6.59 <0.0001
Change in arch depth 0.15 1.16 0.06 1,096 2.51 0.0121
Logit[P(GR=1)]
= 8.68 − 0.26 (pre-treatment keratinized ginigval height)
− 0.68 (post-treatment keratinized gingival height)
− 0.23 (post-treatment intercanine width)
+ 0.15 (change in arch depth)

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 Gingival recession after orthodontic therapy

Table III Best predictors of gingival recession with adding the non-extraction variable

Effect Estimate Exponentiated estimate SE DF t P value

Intercept 8.49 0.96 98 8.82 <0.0001
Pre-treatment keratinized gingival height −0.26 0.77 0.10 1,096 −2.61 0.0092
Post-treatment keratinized gingival height −0.68 0.51 0.13 1,096 −5.06 <0.0001
Post-treatment intercanine depth −0.23 0.80 0.03 1,096 −6.58 <0.0001
Change in arch depth 0.14 1.15 0.06 1,096 2.13 0.0336
Non-extraction 0.27 1.31 0.51 1,096 0.53 0.5981
Logit[P(GR=1)]
= 8.49 − 0.26 (pre-treatment keratinized ginigval height)
− 0.68 (post-treatment keratinized gingival height)
− 0.23 (post-treatment inter-canine width)
+ 0.14 (change in arch depth) + 0.27 (non-extraction treatment)

Table IV Pre-treatment mandibular symphysis width as a predictor of gingival recession

Effect Estimate Exponentiated estimate SE DF t P value

Intercept 5.21 1.31 98 3.97 0.0001
Pre-treatment mandibular symphysis width −0.75 0.47 0.22 500 −3.46 0.0006
Logit[P (GR=1)]
= 5.21 − 0.75 (pre-treatment mandibular symphysis width)

Table V Post-treatment mandibular symphysis width as a predictor of gingival recession.

Effect Estimate Exponentiated estimate SE DF t P value

Intercept 5.56 1.13 99 4.93 <0.0001
Post-treatment mandibular symphysis width −0.94 0.39 0.21 499 −4.37 <0.0001
Logit[P(GR=1)]
= 5.56 − 0.94 (post-treatment mandibular symphysis width)

Other studies have shown that proclination of mandibular height of ≥2 mm are less susceptible to gingival reces-
incisors does not result in gingival recession [7, 22, 23]. sion [29]. It was also noteworthy that in this study an
On the contrary, reclining lower incisors in class III increase in the pre- and post-treatment keratinized gin-
patients tends to increase the risk of gingival recession gival height was significantly related to a decrease in
[24]. In our study, there was no statistically significant gingival recession.
relation between incisal inclination and gingival recession. Despite the fact that no differences found, various
However, anterio-posterior or labial movement of inci- treatment strategies were very close statistical significance
sors demonstrated by the change in arch depth was found (P = 0.058). This is probably due to the relatively small
to be statistically significant with gingival recession. There sample size of patients which was further divided into
are higher chances for gingival recession in the facial three unmatched groups. In addition, the study did not
gingiva when anterior teeth are tipped labially. include the assessment of gingival recession on posterior
Mandibular symphysis dimension is an important teeth. Furthermore, this study did not assess lingual
aspect to be evaluated before incisors movement is planned gingival recession. Statistical analysis was performed for
[25]. Patients with narrow and high symphysis are found both upper and lower arches as one data pool.
to be more susceptible to bone dehiscence and gingival
recession [25–27]. This outcome corroborates with the
findings of our study where patients have minimum chance Conclusions
of gingival recession with wider pre-treatment and post-
treatment symphysis widths. Research indicates that gin- Regardless of any orthodontic treatment modality,
gival morphology plays an important role in orthodontic increased keratinized gingival height, mandibular symphy-
treatment decisions [28]. Teeth with keratinized gingival sis width, and post-treatment intercanine width lower the

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 Sawan et al.

risk of gingival recession. However, increasing arch depth 13. Wennstrom JL, Lindhe J, Sinclair F, Thilander B: Some periodontal
tends to increase gingival recession. Non-extraction treat- tissue reactions to orthodontic tooth movement in monkeys. J Clin
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Funding sources: This research was not funded by any institute. (2008)
15. Slutzkey S, Levin L: Gingival recession in young adults: Occurrence,
Authors’ contribution: NS designed the study. NS, AG, KS, and SL severity, and relationship to past orthodontic treatment and oral
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Conflict of interest: The authors declare no conflict of interest.
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