Case: Gingival recession/Erosion #24 and #25

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Posted on By Carla Monteiro In Periodontics

46 year old female patient; medical history non contributory. In 2010, the patient had presented with minor crowding on the maxillary & mandibular arches. Periodontal probing revealed were WNL (2-3mm ranges) throughout. Invisalign treatment was done in 2010-2011. After completion of invisalign, the patient was seen by a periodontist for gingival grafting of the lower centrals, #24 and #25. In 2013, Gingival grafting with Alloderm was completed. The patient has also whitened her teeth. She wears vivera retainers at night. I’m concerned about progression of the the recession/erosion areas associated with tooth #24 & #25 and what could be causing it in addition to parafunctional habits and if there is any recommendation on how to treat the area? Below are her Before and After Photos, any recommendations, suggestions would be appreciated.

After Grafting - 2017
2017 After Grafting

Before- 2011
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If you can add a radiograph. This is classic occlusal trauma plus inflammation induced periodontitis. This patient needs the teeth SPLINTED with lingual bonded retainers, occlusal adjustment to avoid contact in IC, OHI and SC/RP followed by will never get her papilla back or fix entirely the labial recession but it will improve and can keep her dentate for a long while. Good luck Dr. Salama


Hi Carla;
I would like to both agree and disagree with my friend Maurice.

This is classic occlusal trauma not due to parafunction but to orthodontically placing the teeth the the wrong position which created a lack of harmony. This is an example of man made parafunction which causes the muscles to fire to obtain harmony.

Rework the case orthodontically to place the teeth in the correct position OR stop using retainers and let the teeth move back to a position of occlusal harmony. The palatal and lingual inclination of the teeth clearly indicate that the teeth are in the wrong place. The recession confirms this diagnosis.

Fortunately, it is possible to close the mandibular anterior black triangle with bonding.



I said occlusal trauma but do not disagree that it was ortho induced, it clearly was.
Good point. No ortho until tissue grafting.
Good discussion. regards Maurice


Thank you for the recommendations; I have attached the initial x-ray before invisalign and a recent x-ray.
Here is a little more history - the patient had minor orthodontic movement with invisalign, the gingival tissues were stable. In July 2013 grafting was done w/ Alloderm, the patient and periodontist were not happy with the results and the area was regrafted in Sept. 2014 with a Connective tissue graft in the #24/#25 area.
Prior to grafting the first time, the patient's tissue was stable, just not ideal. Reflecting back on the case, the gingival coverage was at its best proir to grafting. I'm concerned that additional grafting & orthodontics will only worsen the results. I'm leaning toward Dr. Salama's recommendation of adjusting the occlusion and placing a lingual retainer. Any more thoughts?

January 2010
May 2017


Attached are additional photos - Pre-Invisalign

Pre-Invisalign March 2010
Pre-Invisalign March 2010


What could have caused the upper jaw buccal erosions?
There should be something in the social history,diet etc.
Also the lower frenulum attachment is too high.
For sure ,due to the bioform of the upper centrals,there is an interfence in protrusion,which will be a real challenge only with adjustment to be addressed.


Please write more on the dietary lifestyle of the patient which might have been the major factor causing this issue.


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