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Perceptions of NZ orthodontists and periodontists on the management of

gingival recession in orthodontic patients

Article in Australian Dental Journal · May 2022

DOI: 10.1111/adj.12914

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 Australian Dental Journal 2022; 0: 1–9

doi: 10.1111/adj.12914

Perceptions of NZ orthodontists and periodontists on the

management of gingival recession in orthodontic patients
T Wang,* R Zhao,* R Yang,* Y Li,* HL Lien,* L Mei,* G Nogueira*
*Department of Oral Sciences, Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand.

ABSTRACT
Background: This study aimed to investigate the perceptions and opinions of orthodontists and periodontists on the
management of gingival recession in orthodontic patients.
Methods: An online survey was sent to 29 periodontists and 80 orthodontists registered and currently practising in New
Zealand. All participants answered questions about the timing and clinical indications of mucogingival surgeries in
orthodontic patients diagnosed with mucogingival deformities.
Results: Most periodontists and orthodontists believed that gingival grafts should ideally be performed after orthodontic
treatment. In clinical practice, 40% of periodontists indicated that they would receive referrals after completion of
orthodontic treatment. However, 29.6% of orthodontists indicated that they would refer to a periodontist before
orthodontic treatment in clinical practice. The most crucial factor that affected periodontists’ decision-making was
’evidence-based guidelines’ (35.0%), followed by ’clinical experience’ (30.0%) and ’patient concerns’ (15.0%). All four
factors of ’gingival phenotype’, ’presence of gingival recession’, ’amount of keratinised tissue’ and ’planning specific
tooth movements’ were equally considered by orthodontists regarding their decision-making.
Conclusions: The majority of the surveyed New Zealand periodontists and orthodontists expressed a belief that the ideal
timing for the management of gingival recessions would be after the completion of orthodontic treatment.
Keywords: mucogingival deformities, gingival graft, orthodontic treatment, gingival recession, keratinised tissue.
Abbreviations and acronyms: CAF = coronally advanced flap; CEJ = cementoenamel junction; CTG = connective tissue graft; FGG =
free gingival graft; GTR = guided tissue regeneration; MGJ = mucogingival junction.
(Accepted for publication 4 May 2022.)

apically separated by a distinct border called the

INTRODUCTION
mucogingival junction (MGJ).4
In recent years, the general public has shown The concept of biological width refers to the
increased self-awareness and a stronger desire for per- attached soft tissue that covers the tooth structure
ceived dentofacial attractiveness, increasing the coronal to alveolar bone crest.5 Histologically, the
demand for orthodontic treatment.1,2 However, the mean value of biological width is 2.04mm, which
development of gingival recession may be a risk fol- consists of 0.97mm of epithelial attachment, and
lowing orthodontic tooth movements, subsequently 1.07mm of connective attachment.6 The histological
compromising harmonious dentofacial aesthetics.3 and clinical evidence suggests that biological width
The gingival tissue is a part of the masticatory substantially impacts periodontal health. The violation
mucosa covering the alveolar bone and surrounding of biological width is considered a significant prob-
the cervical portion of the tooth. It consists of an lem. It can irritate the gingival tissue to initiate gingi-
epithelial layer and an underlying connective tissue val inflammation leading to the loss of periodontal
called lamina propria. Coronally, the free gingiva ligament, resorption of bone and consequently gingi-
appears coral pink clinically and lies from the gingival val recession.6,7
margin to the level of cementoenamel junction (CEJ), According to the most updated classification scheme
which is usually 1–2mm.4 The attached gingiva is for periodontal and peri-implant diseases, gingival
continuous, with free gingiva in the apical direction. recession is classified as a mucogingival deformity
The loose, darker red alveolar mucosa can be seen around the tooth.8,9 Gingival recession is defined as

© 2022 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association. 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
T Wang et al.

an apical shift of mucogingival tissue to the CEJ, deformities in orthodontic patients to assist in devel-
resulting in root exposure.10 Several previous studies oping a universal guideline for clinicians.
have reported that gingival recession can develop dur-
ing orthodontic treatment.9,11–13 A buccal tooth
METHODS
movement may reduce the buccal-lingual thickness of
the gingiva, which is a factor for the progression of Ethics approval was obtained from the University of
mucogingival deformities, especially when combined Otago Human Ethics Committee (reference number:
with inappropriate oral hygiene habits and traumatic D21/034). This study took place over a period of 6
tooth brushing techniques.14 It is equally important to months in 2021, and surveyed orthodontists and peri-
recognise that a non-controlled orthodontic force can odontists currently registered and practicing in New
harm the periodontium.15 A recent study reported a Zealand.
5% to 12% prevalence of gingival recession immedi- All participants gave their consent in the first ques-
ately following orthodontic treatment.9 Additionally, tion of the questionnaire distributed. Orthodontists
5-year follow up studies that were performed reported and periodontists currently registered and practising
an increased prevalence of up to 47%.9 Gingival in New Zealand were invited via emails to complete
recession as a mucogingival deformity is not only aes- an online questionnaire generated using Qualtrics soft-
thetically undesirable but can also increase the risk of ware (Qualtrics, Provo, UT) between January and
dentine hypersensitivity, carious and non-carious cer- June in 2021. To determine the perceptions & opin-
vical lesions.16 ions of orthodontists and periodontists in New Zeal-
However, the effects of orthodontic forces on the and regarding when gingival grafting should be
periodontium can vary, dependent on the type of performed concerning orthodontic treatment, survey
tooth movement. Some studies proposed that questions were distributed separately to orthodontists
orthodontic movement within the alveolar bone poses and periodontists registered with the Dental Council
a minimal risk of gingival recession.17,18 This view is of New Zealand (DCNZ). Of the 45 periodontists
supported by a recent systematic review which and 142 orthodontists registered with DCNZ, 16 peri-
reported that orthodontic treatment has minimal odontists and 62 orthodontists had non-valid email or
adverse effects on the periodontium.15 Interestingly, duplicate email addresses, leaving 29 periodontists
some studies report that specific orthodontic proce- and 80 orthodontists that were included in the study.
dures are beneficial to gingival recession and oral There were five questions in total – two general
hygiene by increasing dental cleansability.14 Further- questions and three questions dedicated to orthodon-
more, lingual tooth movement may increase the thick- tists and periodontists each specifically. The two gen-
ness of the buccal mucogingival complex. As a result, eral questions asked participants to identify their
any existing gingival recession may decrease, and it dental specialty and their years of clinical experience.
may not be necessary to perform gingival graft The three specific questions asked about the timing of
surgery before any planned lingual movement of when the referral for gingival graft treatment was
teeth.19 made or received and the factors which affected their
The lack of keratinised tissue was previously con- decision-making. Responses for the timing question
sidered a factor for developing inflammation and gin- included before, during, after orthodontic treatment
gival recession. When oral hygiene is compromised or ‘other’. Factors influencing their decision-making
commonly seen in patients undergoing orthodontic included four different categorical variables and
treatment, the attached gingiva becomes an essential ‘other’.
factor for maintaining gingival health.20 Friedman The ’other’ option was provided to allow for open
first introduced mucogingival surgery in the 1950s to answers to minimise researcher bias. An inductive
preserve the attached gingiva. Surgical procedures approach was used to analyse the collected qualitative
such as guided tissue regeneration (GTR), coronally data. Participants who responded ’other’ were
advanced flap (CAF), free gingival graft (FGG) and reviewed, and repeating themes were identified. Rele-
subepithelial connective tissue graft (SCTG) have been vant quotes were allocated into themes and are pre-
indicated to prevent or correct gingival recession and sented in Table 2. Identified themes were discussed
improve aesthetics.16,21–23 However, there is currently and refined to maximise consistency and validity dur-
a lack of a consensus in the form of an internationally ing the analysis. We aimed to comprehensively inter-
accepted guideline, and much controversy remains pret data collected by performing continuous data
regarding the timing of when mucogingival surgeries analysis until no new themes could be identified.24
should be performed concerning orthodontic treat- In addition, a literature review was performed to
ments. Therefore, this study explores the differences corroborate the findings of our survey. Two hundred
in perceptions and opinions between orthodontists and eighteen studies indexed in PubMed were
and periodontists on the management of mucogingival included through searching for the keywords "gingival
2 © 2022 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
 Gingival recession in orthodontic patient

recession" and "orthodontic patients" via the End-

Note PubMed Online Search function. Case reports
and case series were excluded from the study due to
low-level evidence. Thirty studies were left after
screening the titles and abstracts. The full texts of all 26.7

30 studies were then read, leaving 18 studies at the

end assessed as being valuable to our study.
40

RESULTS
The response rate was 51.7% among periodontists
(15 out of 29) and 36.2% among orthodontists (29
out of 80). Amongst participants, roughly 50% of
both periodontists and orthodontists had been practis-
ing for more than 20 years (Table 1).
In clinical practice, the most significant proportion
of periodontists surveyed reported that they would
generally receive referrals from orthodontists for gin- 26.7

gival graft treatment after (40.0%) orthodontic treat- 6.7

ment, followed by a similar proportion reporting

receipt of referrals before (26.7%) or during all three
phases (26.7%) of orthodontic treatment. Only a sin- AŌer During Before All three phases

gle periodontist (6.7%) reported primarily receiving Fig. 1 Responses reported by periodontists to the question "In which
phase of the orthodontic treatment do you generally receive referrals for
referrals during orthodontic treatment (Fig. 1). gingival grafts from an orthodontist?"
In clinical practice, roughly a third of orthodontists
surveyed indicated that they would refer patients for
gingival graft treatment before commencing treatment gingival recession etc. Comments made by the
(29.6%). A smaller proportion indicated that they orthodontists are presented in Table 2. Analysis of the
would refer after treatment (14.8%) or not at all open comments made by orthodontists revealed that
(7.4%). Almost half (48.1%) of orthodontists sur- the vast majority believed that they would make a
veyed selected ’other’ regarding when to refer patients referral to a periodontist for an initial consultation
for gingival graft treatment in clinical practice before commencing treatment, but leave the treatment
(Fig. 2). Among the orthodontists who chose the for after completion of treatment.
option ‘other’, the majority (61.5%) mentioned refer- The most significant proportion of periodontists
ring patients to periodontists for a second opinion. surveyed believed that the ideal timing of gingival
The following comment exemplifies this: graft treatment should be performed after orthodontic
treatment (42.9%), followed by before orthodontic
"I would encourage the patient to have a peri- treatment (21.4%). No periodontists surveyed
odontist consultation first before orthodontic believed that gingival graft treatment should be per-
treatment." formed during orthodontic treatment or not at all.
Approximately a third of the periodontists surveyed
The remaining orthodontists who selected ’other’ indicated that the timing of gingival graft treatment is
(38.5%) believed it is dependent on various factors dependent on each case, and factors such as patients’
such as particular tooth movement, the severity of age and possible progressive attachment loss due to
tooth movement should be taken into account (Fig. 3,
Table 2). The following comment exemplifies this:
Table 1. Years of practising experience reported by
study participants "If the tissue is delicate and tooth movement
may lead to progressive loss of attachment, then
Periodontists Orthodontists Total
grafting before ortho is indicated, but generally I
Years in practice prefer to wait until after completion of
<5 2 2 4
5-10 3 3 6
orthodontic treatment."
10-15 1 5 6
15-20 2 5 7 Similarly, the largest proportion of orthodontists
> 20 7 14 21 surveyed also believed that the ideal timing of gingival
Total 15 29 44
graft treatment should be performed after orthodontic
© 2022 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association. 3
T Wang et al.

Do not refer,
7.4

Refer for second

opinion, 29.6
AŌer , 14.8

Other, 48.1

Dependent on each
Before, 29.6 case, 18.5

Before AŌer Do not refer Refer for second opinion Dependent on each case
Fig. 2 Responses reported by orthodontists to the question "If the patient presents with mucogingival conditions such as gingival recession or insufficient
keratinised tissue width, when do you refer the patient for gingival graft?"

Table 2. Open comments made by participants selecting ‘other’ in response to questions throughout the survey
When do orthodontists refer the patient for gingival graft treatment in clinical practice?
Refer for a second opinion
#18 "before (for patient information) with a view to correction after the braces."
#25 "refer them[patient] to a periodontist for consult and treatment planning ideas."
#27 "seek periodontists’ opinion."
#33 "opinion from periodontists before surgery, not until after[consultation]"
#34 "referral for opinion by periodontists."
#37 "I will decide on timing. The timing of graft placement with my local periodontist."
#40 "I would refer for an opinion before treatment but gingival graft likely to be left till after orthodontic treatment."
#35 "Depends upon what your orthodontic treatment involves and will this have an impact on the pre-existing recession, I would encourage
the patient to have a periodontist consultation first before orthodontic treatment."
Depending on each case
#24 "depends on the cases."
#26 "moderate [gingival recession] – monitor and refer at the end of treatment. Severe [gingival recession]-refer pre-treatment”
#31 "all of the above it influences my treatment plan."
#36 "it depends. If I think this tooth will get worse with ortho and is in a position where it can be grafted, I will refer for a graft before
orthodontic treatment."
#41 "it depends."
What is the ideal timing of gingival graft treatment in periodontists’ opinions?
It depends on each case
#09 "if the tissue is delicate and tooth movement may lead to progressive loss of attachment, then grafting before ortho is indicated, but
generally I prefer to wait until after completion of orthodontic treatment."
#15 "it is situation-dependent"
#21 "depends on the clinical situation. After orthodontic treatment is more common than before treatment."
#22 "depends."
#44 "depends on whether the patient is an adolescent or adult."
What is the ideal timing of gingival graft in orthodontists’ opinion?
It depends on each case
#10 "it varies from case to case – sometimes before and sometimes after."
#26 "as above [all conditions mentioned in Figure 5]."
#27 "case-by-case basis."
#31 "depends, there is a shift that some orthodontists will do pre-orthodontic treatment graft."
#29 "before and consent patients for after as well."
#37 "depends on the specifics of the cases."
Consultation with periodontists (n=4)
#24 “in consultation with periodontist”
#25 “when the periodontist says”
#32 “recommendation of periodontist”
#34 “Normally advised by periodontist to do this after”

4 © 2022 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
 Gingival recession in orthodontic patient

Periodontists surveyed considered ’evidence-based

guidelines’ to be the most important factor affecting
clinical decision-making (35.0%), followed by ’clinical
experience’ (30.0%) and ’patient complaints of aes-
thetic, discomfort or tooth sensitivity’ (15.0%)
(Fig. 5). Interestingly, no periodontists believed that a
35.7 referral from orthodontists would significantly impact
their decision-making. Those who selected ’other’
42.9 commented on factors such as ‘anatomical condition
and tissue biotype’, ’difficulty of home care’ and ’a
combination of evidence, experience and patient-
based factors’ (Table 2).
Comparatively, orthodontists surveyed considered
several factors to be equally important in affecting
their clinical decision-making – planning specific tooth
movements (22.9%), amount of keratinised tissue
(24.1%), gingival phenotype (24.1%) and presence of
gingival or soft tissue recession (26.5%) (Fig. 6).
21.4
DISCUSSION

AŌer Before Depends on each case There is ambiguity in the literature regarding the
impact of orthodontic treatment on the development
Fig. 3 Periodontists’ beliefs on the ideal timing of gingival graft treat-
ment in orthodontic patients with gingival recession or insufficient kera- of mucogingival deformities. This study investigated
tinised tissue width. the opinions of New Zealand periodontists and
orthodontists on the timing of management of
mucogingival deformities in orthodontic patients,
treatment (48.1%), followed by before orthodontic along with the factors which may influence their
treatment (7.4%) and no referral at all (7.4%). No decision-making. Most periodontists in the study gen-
orthodontists surveyed believed that the ideal timing erally received referrals from orthodontists for treat-
is during orthodontic treatment. A considerable pro- ment of gingival recession after the completion of
portion of orthodontists indicated that it would be orthodontic treatment whereas most orthodontists in
dependent on each case (22.2%) or that it would be the study reported that they commonly referred to
necessary for a consultation with a periodontist periodontists before orthodontic treatment to seek a
(14.8%) (Fig. 4). second opinion. This discrepancy could be due to a

Do not
Before,
refer,
7.4
7.4 Dependent on each
case , 22.2

Other, 37

AŌer, 48.1 ConsultaƟon with

periodonƟsts, 14.8

AŌer Before Do not refer Dependent on each case ConsultaƟon with periodonƟsts
Fig. 4 Orthodontists’ beliefs on the ideal timing for gingival graft treatment in orthodontic patients with gingival recession or insufficient keratinised tis-
sue width.
© 2022 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association. 5
T Wang et al.

20

35

15

30

Clinical guidelines Clinical experience PaƟent complaint of aestheƟcs, discomfort or sensiƟvity Other

Fig. 5 Factors affecting clinical decision-making reported by periodontists.

2.4

22.9
26.5

24.1

24.1

Planning specific tooth movements Amount of keraƟnised Ɵssue

Gingival phenotype Presence of gingival or soŌ Ɵssue recession
Other
Fig. 6 Factors affecting clinical decision-making reported by orthodontists.

lack of a consensus in the literature regarding whether referral for consultation with a periodontist. This was
the orthodontic treatment causes the development of evident in their responses to a subsequent question in
mucogingival deformities. Traditionally, it has been which they indicated that they believed the ideal tim-
thought that orthodontic treatment is a potential cau- ing for gingival grafts was after orthodontic treat-
sative factor of gingival recession.11 Thus, post-ortho ment.
grafts may still be necessary even after a pre-ortho Slutzkey and Levin (2008) reported the risk of
graft has been performed. This discrepancy may also developing gingival recession in young adults (18-
be due to a misunderstanding of the survey question: 22 years old) who had received orthodontic treatment
the orthodontists may have misinterpreted the referral was doubled compared with those untreated.25 This
for the performance of gingival graft treatments as a agrees with Renkema et al. (2013), who found that
6 © 2022 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
 Gingival recession in orthodontic patient

orthodontically treated patients demonstrated a higher phases of treatment in clinical practice and why an
prevalence of labial gingival recessions than untreated internationally accepted guideline has yet to be devel-
controls at all time points of orthodontic treatment.26 oped.
Additionally, Allias and Melsen (2003) also found Due to the lack of research investigating the ideal
that adult orthodontic patients had a significantly timing of gingival graft treatment in orthodontic
higher prevalence of gingival recession in at least one patients with mucogingival deformities, there is poor
lower incisor in comparison with untreated controls.27 consistency in clinical decision-making amongst clini-
This is consistent with the present study’s findings, cians as reflected in the results of our study (Figs 1-4).
where most periodontists and orthodontists surveyed There are very few studies published to date that have
agreed that the ideal timing for gingival graft treat- concluded the ideal timing of gingival graft treatment
ment in orthodontic patients presenting with gingival in orthodontic patients with mucogingival deformities.
recession was after the completion of orthodontic One study conducted by Maynard & Ochesenbein
treatment to prevent the need for a repeat of gingival (1975) investigated the prevalence of mucogingival
graft treatment. The findings of Ngan et al. (1991) deformities in 100 children who were anticipating
have also emphasised that pre-orthodontic gingival orthodontic treatment.38 The authors recommended
grafting did not decrease the risk of post-orthodontic that a free gingival graft should be performed before
gingival recession.28 tooth movement in the presence of insufficient kera-
Conversely, Gebistorf et al. (2018) concluded that tinised tissue. If there is 1mm or less keratinised tis-
those who have had orthodontic treatment had a simi- sue, then grafts are recommended; grafts would not
lar impact on long-term periodontal health compared be recommended when there is over 1mm of attached
with untreated malocclusion.29 Furthermore, no rela- gingiva.38,39 This appears to conflict with the results
tionship between functional appliances and gingival found in our current study, where the most significant
recession was found.26,30 It has been suggested that proportion of periodontists and orthodontists sur-
orthodontic treatment is not considered a risk factor veyed believed that the ideal timing for gingival graft
for developing mucogingival deformities if other treatment would be after the completion of orthodon-
established risk factors are well-controlled.31–34 Pango tic treatment. However, the recommendation by May-
Madariaga et al. (2020) proposed that if oral hygiene nard & Oschesenbein for pre-ortho gingival grafting
is well maintained, orthodontic treatment does not is based on the premise that the patient exhibits the
impact periodontal health.34 Moreover, if periodontal early presence of inadequate dimensions of keratinised
phenotype were respected, tooth proclination in lower tissue to prevent the progression of the pre-existing
incisors and canines would not risk labial gingival mucogingival problems. Thus, this would likely be a
recession. Still, the gingival thickness would be case of ’dependent on each case’ indicated by partici-
expected to decrease.35 However, these risk factors pants of our present study. Alternatively, this appar-
could be altered by orthodontic treatment. For exam- ent conflict could also possibly be due to advances
ple, a facial tooth movement may result in a thin phe- and changes in scientific knowledge and understand-
notype that predisposes to developing mucogingival ing regarding the impact of orthodontic treatment in
deformities.19 A systematic review conducted by Klou- the development of mucogingival deformities over the
kos et al. (2014) concluded that gingival graft treat- past few decades. Therefore, in the absence of a clear
ment before orthodontic treatment could be clinically & concise evidence-based clinical guideline for
viable and beneficial to preventing the development or managing gingival recession in orthodontic patients,
progression of gingival recession in high-risk patients practitioners may find the issue challenging and rely
with ‘thin’ gingival phenotype; however, this treat- more on clinical experience and judgement when
ment approach is not based on solid scientific evi- deciding when to perform corrective treatment for
dence. The same group also expressed concern mucogingival deformities in orthodontic patients.
regarding whether or not this pre-emptive periodontal Consequently, this would partially explain the incon-
intervention was necessary or considered over- sistencies in decision-making observed in the present
treatment, suggesting that it was possible to wait until study, which necessitates a need for our dental profes-
the potential gingival recession became pathological sional bodies or an organisation with large outreach
before intervening.36 to issue a guideline or protocol to promote evidence-
Additionally, maintenance of oral hygiene may be based practice and consistency amongst practitioners.
compromised during orthodontic treatment. Boke
et al. (2014) suggested that fixed appliances were pos-
CONCLUSIONS
itively correlated with plaque accumulation and the
development of overall gingival recession.37 This con- This study has provided valuable insight into the ideal
troversy in the literature may explain why orthodon- timing for when orthodontic patients presenting with
tists in the present study may refer during different mucogingival deformities should be referred for
© 2022 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association. 7
T Wang et al.

gingival graft treatment. Before this study, there has 12. Joss-Vassalli I, Grebenstein C, Topouzelis N, Sculean A, Kat-
saros C. Orthodontic therapy and gingival recession: a system-
been a lack of research on this topic due to the ambi- atic review. Orthod Craniofac Res 2010;13:127–141.
guity in the literature regarding the impact of
13. McComb JL. Orthodontic treatment and isolated gingival reces-
orthodontic treatment on the development of sion: a review. Br J Orthod 1994;21:151–159.
mucogingival deformities. Our results have revealed 14. Chatzopoulou D, Johal A. Management of gingival recession in
the inconsistencies in clinical decision-making regard- the orthodontic patient. Semin Orthod 2015;21(1):15–26.
ing the treatment of these defects and helped better 15. Fan J, Caton JG. Occlusal trauma and excessive occlusal forces:
understand the views of New Zealand periodontists narrative review, case definitions, and diagnostic considera-
tions. Journal of periodontology. 2018;89:S214–S222.
and orthodontists on the optimal timing and indica-
16. Prato GP, Clauser C, Cortellini P. Periodontal plastic and
tions for gingival graft treatment in orthodontic mucogingival surgery. Periodontol 2000. 1995;9(1):90–105.
patients. Future studies should conduct randomised 17. Wennstr€
om JL, Lindhe J, Sinclair F, Thilander B. Some peri-
clinical trials to assist the development of evidence- odontal tissue reactions to orthodontic tooth movement in
based guidelines for clinical use. monkeys. J Clin Periodontol 1987;14:121–129.
18. Ruf S, Hansen K, Pancherz H. Does orthodontic proclination
of lower incisors in children and adolescents cause gingival
ETHICS APPROVAL recession? Am J Orthod Dentofacial Orthop 1998;114:100–
106.
Ethics approval for this study was granted by the 19. Wennstr€om JL. Mucogingival considerations in orthodontic
University of Otago Human Ethics Committee (refer- treatment. Semin Orthod 1996;2:46–54.
ence number: D21/034). 20. John V, Langer L, Rasperini G, et al. Periodontal soft tissue
non–root coverage procedures: practical applications from the
AAP regeneration workshop. Clin Adv Periodontics 2015;5:11–
ACKNOWLEDGEMENTS 20.
21. Friedman N. Mucogingival surgery. Tex Dent J 1957;75:358–
The authors would like to thank all participants for 362.
their time and contribution to the study. 22. Deo SD, Shetty SK, Kulloli A, et al. Efficacy of free gingival
graft in the treatment of Miller Class I and Class II localized
gingival recessions: a systematic review. J Indian Soc Periodon-
CONFLICT OF INTEREST tol 2019;23:93.
All authors have no conflict of interest to disclose. 23. Pini-Prato G, Magnani C, Zaheer F, Rotundo R, Buti J. Influ-
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