ORIGINAL ARTICLE

Prevalence of gingival recession after

orthodontic tooth movements
Jason W. Morris,a Phillip M. Campbell,b Larry P. Tadlock,b Jimmy Boley,b and Peter H. Buschangb
San Diego, Calif, and Dallas, Tex

Introduction: This study was designed to evaluate the long-term prevalence of gingival recession after
orthodontic tooth movements, focusing on the effects of mandibular incisor proclination and expansion of
maxillary posterior teeth. Methods: Records of 205 patients (162 female, 43 male) were obtained from 2 private
practice orthodontists. Using pretreatment (age, 14.0 6 5.9 years) and posttreatment (age, 16.5 6 6.0 years)
lateral cephalograms and dental models, mandibular incisor proclination and maxillary arch widths were
measured. Gingival recession was measured based on posttreatment and postretention (age,
32.3 6 8.5 years) intraoral photographs and models. Associations between tooth movements and gingival
recession were evaluated statistically. Results: Only 5.8% of teeth exhibited recession at the end of orthodontic
treatment (only 0.6% had recession .1 mm). After retention, 41.7% of the teeth showed recession, but the
severity was limited (only 7.0% .1 mm). There was no relationship between mandibular incisor proclination dur-
ing treatment and posttreatment gingival recession. Incisors that finished treatment angulated (IMPA) at 95 or
greater did not show significantly more recession than did those that finished less than 95 . There were weak
positive correlations (r 5 0.17-0.41) between maxillary arch width increases during treatment and posttreatment
recession. Conclusions: Orthodontic treatment is not a major risk factor for the development of gingival reces-
sion. Although greater amounts of maxillary expansion during treatment increase the risks of posttreatment
recession, the effects are minimal. (Am J Orthod Dentofacial Orthop 2017;151:851-9)

G
ingival recession refers to the exposure of the
tooth's surface by an apical shift of the gingiva.1
Recession is important because it can lead to
poor esthetics,2,3 tooth hypersensitivity,4 loss of peri-
odontal support,5 difficulties in maintenance of oral hy-
giene,6,7 and increased susceptibility to caries.8-10
Although its etiology is not fully understood,
periodontal disease11-13 and mechanical trauma11,14,15
are considered the primary factors in the pathogenesis
of gingival recession.
Orthodontic treatment might also promote the devel-
opment of gingival recessions.16 It has been well estab-
lished that orthodontic forces can move roots close to or
through the alveolar cortical plates, leading to bone de-
hiscences.17-19 Since areas of recession always exhibit
a
b
Private Practice, San Diego, Calif.
Department of Orthodontics, Baylor College of Dentistry, Texas A&M Health
Health Science Center, Dallas, Tex
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Peter H. Buschang, Department of Orthodontics,
Baylor College of Dentistry, Texas A&M Health Science Center, 3302 Gaston
Ave, Dallas, TX 75246; e-mail, phbuschang@bcd.tamhsc.edu.
Submitted, April 2016; revised and accepted, September 2016.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.09.027
dehiscences in the subjacent alveolar bone, it is
reasonable to assume that the marginal gingiva,
without proper alveolar bone support, might migrate
apically and expose the root.20 However, animal experi-
ments have demonstrated little or no recession, over the
short term, associated with excessively proclined teeth,
despite the development of bony dehiscences.17-19 This
suggests that either more time may be necessary for
recession to develop or recessions do not necessarily
occur when dehiscences are created.
Clinically, the association between mandibular
incisor proclination and recession remains unclear.
Most studies evaluating recession shortly after treatment
showed no relationship.21-25 The few studies that
investigated the long-term relationship between
mandibular incisor proclination and recession are
controversial; 2 showed no relationship,24,26 and 1
did.27 The study that showed a relationship had a rela-
tively small sample compared with other studies. Only
1 long-term study of adolescents, who represent the
typical orthodontic population, has been conducted.24
It is also important to evaluate the association between
recession and maxillary expansion. Expansion causes
dental tipping and loss of buccal alveolar bone, which
could increase the risk of recession.17,19,28
851
852
The purpose of this study was to evaluate the long-
term prevalence of gingival recession after orthodontic
movement of the mandibular incisors, maxillary premo-
lars, and maxillary first molars. It will be the first study to
evaluate the long-term effects (approximately 16 years
posttreatment at 32.3 years of age) effects of maxillary
expansion on the buccal soft tissues. The specific aims
were the following.
1. Determine the prevalence and extent of recession
immediately after orthodontic treatment and after
a long-term follow-up period.
2. Evaluate the relationships between mandibular
incisor proclination during treatment and long-
term recession.
3. Evaluate the relationship between maxillary expan-
sion during treatment and long-term recession.
MATERIAL AND METHODS
A retrospective sample of 327 patients from 2 private
orthodontic practices in Arlington and Dallas, Tx was
evaluated. The selection criteria included records at the
beginning of treatment (T1), the end of treatment (T2),
and at long-term (at least 2 years after appliances
removal) follow-up (T3). Treatments lasted an average
of 2.5 years, starting at age 13.9 6 5.9 years and ending
at 16.5 6 6.0 years. The long-term follow-up occurred at
age 32.3 6 8.5 years. A total of 205 patients were
included in the study. Missing records or records taken
too close to the appliance removal date were the reasons
that all patients were not included in the study. Female
subjects comprised the majority (78.7%) of the sample.
Approximately 59.9% of the sample was treated with pre-
molar extractions; approximately 6% had second premo-
lar extractions. The sample included 92 (44.5%) Class I
subjects, 109 (52.7%) Class II subjects, and 6 (2.9%) Class
III subjects. Most patients were retained for 3 years. Some
had their retainer removed by their general dentist before
3 years. To eliminate the possibility of inflamed gingiva
obscuring the gingival recession, patients were excluded
if the final treatment models and intraoral photographs
were taken less than 2 weeks after debonding of the
appliance. The T2 records of patients in this study were
taken 4 to 8 weeks after debonding. Two patients had
congenitally missing mandibular incisors.
For each subject, the frontal and buccal intraoral
photographs taken at T2 and T3 were evaluated. In
addition, their cephalometric radiographs were evalu-
ated at T1 and T2. The intraoral photographs and ceph-
alometric radiographs were scanned (300 pixels/in).
Five standardized photographs (maxillary occlusal,
maxillary frontal, maxillary right buccal, maxillary left
buccal, and mandibular frontal) of the models, along
May 2017  Vol 151  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Morris et al
with a millimeter ruler used for calibration, were taken
at T1, T2, and T3. Information pertaining to ethnicity,
Angle classification, expansion type (rapid palatal
expansion or archwire), extractions, retention type,
retention duration, and dates were obtained from the
patients’ charts.
Recession was measured bilaterally on the mandib-
ular incisors, the maxillary premolars, and the maxillary
first molars at T2 and T3. A score of 0 was recorded if
the CEJ was not visible. Recession on the mandibular in-
cisors was defined as the distance between the gingival
margin and the cementoenamel junction on the midfa-
cial surface.21,22,26,28,29 Due to measurement variability,
recession on the facial aspect of the maxillary first molars
was defined as the maximum distance from the gingival
margin to the cementoenamel junction anywhere on the
maxillary first molars. When possible, intraoral
photographs were used to measure recession because
they are more reliable than dental models.22
All images were imported into Viewbox cephalo-
metric software (version 4; dHAL Software, Kifissia,
Greece). The intraoral photographs were calibrated
based on the ratio of the mesiodistal width of the maxil-
lary central incisor at its broadest point, as measured on
the dental model, to the same width measurement on
the intraoral photographs with the following formula.
Mandibular incisor recession 5 photographic
measured recession 3 (mesiodistal width of maxillary
central incisor measured on model O mesiodistal width
of maxillary central incisor measured on photograph).
To measure recession at the maxillary premolars and
first molars, a ratio was established based on the distance
from the gingival margin to the cusp tip of the maxillary
posterior teeth taken on both the models and on the in-
traoral photographs with the following formula.
Maxillary posterior recession 5 photographic
measured recession 3 (distance from gingival margin
to cusp tip of premolar or molar measured on model
O distance from gingival margin to cusp tip of premolar
or molar measured on photograph).
When intraoral photographs were not available or their
quality was poor (approximately 20% of the time), reces-
sion was measured on the scanned models with the View-
box cephalometric software. Using models to measure
recession has been shown to be both valid29 and reliable.22
Technical errors were based on randomly selected sets
of replicates: 20 replicate intraoral photographs and 20
casts and associated intraoral photographs. The system-
atic error for intraoral photographs was not statistically
significant, and the intraclass correlations ranged from
0.962 to 0.981. Systematic differences showed slightly
(0.026 mm) larger measurements on the casts than the in-
traoral photograph measurements for the maxillary first
Morris et al
Fig 1. Cephalogram with landmarks used to calculate the
IMPA, mandibular central incisor to nasion–B-point, and
mandibular plane angle.
molars. Intraclass correlations between cast and intraoral
photograph measurements ranged from 0.931 to 0.959.
Mandibular incisor inclination was measured using the
T1 and T2 cephalometric radiographs from 199 patients (5
were missing). The radiographs were traced using software
(Dolphin Imaging, Chatsworth, Calif) Nine cephalometric
landmarks were recorded at T1 and T2, including sella, na-
sion, A-point, B-point, pogonion, menton, gonion, mandib-
ular incisor tip, and mandibular incisor root apex (Fig 1).
These landmarks were used to calculate 3 angular measure-
ments: IMPA, mandibular central incisor to nasion–B-point
line, and mandibular plane angle. Based on replicate mea-
sures of 20 randomly selected cephalometric radiographs,
there were no statistically significant systematic errors. The
intraclass correlations were 0.997 for IMPA and 0.991 for
mandibular central incisor to nasion–B-point line.
Maxillary intermolar and interpremolar distances
were measured using occlusal photographs of the T1
and T2 models. The models were imported into the
Viewbox cephalometric software and calibrated using
the millimeter ruler at the base of the model. The inter-
molar and interpremolar distances were measured at the
most lingual point at the lingual gingival margin to the
same position on the corresponding contralateral tooth
(Fig 2). Based on replicate measurements of 20 randomly
selected casts, there were no statistically significant sys-
tematic errors. The intraclass correlations were 0.999 for
all arch width measurements.
Statistical analysis
The data were analyzed statistically using software
(version 21; IBM, Armonk, NY). To compare with
American Journal of Orthodontics and Dentofacial Orthopedics
853
Fig 2. Occlusal photograph of a model used to measure
intermolar and interpremolar distances at the most lingual
point at the lingual gingival margins.
previous publications,22,30,31 the teeth were categorized
based on the amounts of recession as follows: no
recession, 0.1 to 1 mm of recession, and greater than
1.0 mm recession. Because the amounts of recession were
not normally distributed, nonparametric statistics were
used to assess the associations (Spearman) and group
differences (Mann-Whitney U).
RESULTS
Average age at T1 was 14.0 6 5.9 years (Table I). Age
at T2 was 16.5 6 6.0 years, with a mean treatment time
of 2.5 6 1.1 years. The mean age at T3 was
32.3 6 8.5 years, and the time between T2 and T3
was 15.8 6 6.3 years.
Recession was evaluated with the sexes combined
because only 1 (maxillary right first premolar) difference
was statistically significant (P 5 0.004). There was little
recession at T2 (Table II), with most (86.5%-97.8%) teeth
having no recession. The mandibular central incisors
showed the most recession, with 12.8% exhibiting 0.1 to
1.0 mm of recession and 0.7% with greater than 1.0 mm.
The maxillary first premolars showed the second highest
prevalence, with 7.9% exhibiting 0.1 to 1.0 mm of reces-
sion, and 1.2% exhibiting more than 1.0 mm of recession.
The mandibular lateral incisors and the maxillary second
premolars and first molars all showed limited amounts of
recession, with less than 4% of the teeth showing recession
at T2. Overall, 18.3% of patients demonstrated gingival
recession on at least 1 tooth after treatment, and 5.8% of
the teeth examined exhibited recession at T2.
Significant (P\0.001) recession occurred between T2
and T3. The maxillary first premolars had the highest prev-
alence of recession at T3. Recession was evident for almost
60% of the maxillary first premolars, but only 7.7%
May 2017  Vol 151  Issue 5
854 Morris et al

Table I. Sample sizes and ages (y) at pretreatment (T1), posttreatment (T2), and long-term follow-up (T3) for the
overall sample and subgroups
T1 T2 T3

Group Subgroup n Mean SD Mean SD Mean SD

Overall – 205 14.0 5.9 16.5 6.0 32.3 8.5
Sex Male 43 13.2 2.4 15.6 2.3 30.5 7.3
Female 162 14.2 6.5 16.8 6.6 32.7 8.7
Treatment Nonextraction 84 13.7 5.7 15.8 5.9 29.6 8.2
Extraction 109 13.8 5.5 16.7 5.5 34.1 7.7
Angle class I 90 14.6 5.9 17.1 6.1 33.3 8.7
II 108 13.0 5.3 15.6 5.3 30.9 8.1

Premolar extraction patients only; Angle Class III patients omitted.

Table II. Percentages of teeth with gingival recession at T2 and T3

Mandibular central Mandibular lateral Maxillary first Maxillary second Maxillary first
incisor (%) incisor (%) premolar (%) premolar (%) molar (%)
Time Recession
point (mm) Left Right Left Right Left Right Left Right Left Right
T2 0 85.3 87.3 96.0 92.8 93.4 88.2 98.0 98.5 97.4 97.5
0.1-1.0 13.2 12.2 3.5 3.0 5.5 10.7 0.5 1.0 2.5 2.0
.1.0 1.5 0.5 0.5 0.0 1.1 1.1 1.5 0.5 0.0 0.5
T3 0 47.8 66.5 59.6 46.8 45.7 35.2 68.0 67.5 63.2 65.1
0.1-1.0 42.0 29.1 37.0 42.9 46.7 57.1 28.4 30.0 33.0 27.5
.1.0 10.2 4.4 3.4 10.3 7.6 7.7 3.6 2.5 3.8 7.4

showed greater than 1.0 mm of recession. The mandibular
central incisors showed the second highest prevalence of
recession at T3, with almost 53% exhibiting recession,
and 10.3% showing greater than 1 mm of recession. The
mandibular lateral incisors, the maxillary second premo-
lars, and the maxillary first molars all showed similar
amounts of recession at T3, with 32% to 37% of the teeth
exhibiting recession. Overall, 55.7% of patients demon-
strated gingival recession on at least 1 tooth at T3, and
41.7% of the teeth examined exhibited recession.
From T2 to T3, the incidence of recession was highest
for the maxillary first premolars and the mandibular cen-
tral incisors (Fig 3). Recession occurred on the maxillary
first premolars 58.1% of the time; 6.7% of the time, it
was greater than 1 mm. For the mandibular central inci-
sors, recession occurred 51.2% of the time; 12.1% of the
time, it was more than 1 mm. Incidences of recession for
the mandibular central incisors and maxillary first pre-
molars were not significantly different (P 5 0.070).
The incidence of recession was less than 36% for the
mandibular lateral incisors, maxillary second premolars,
and maxillary first molars. The incidence of recession
was significantly less (P \0.05) for these 3 teeth than
for the mandibular central incisors and maxillary first
premolars. Recession amounts for the mandibular lateral
incisors, maxillary second premolars, and maxillary first
molars were not significantly different from one another.
A significant (R 5 0.162; P 5 0.026) positive corre-
lation was found between recession of the mandibular
right central incisor and age. The maxilla teeth also
showed significant (P \0.05) associations between age
and recession. There was no statistically significant dif-
ference in posttreatment recession between the Class I
and Class II patients. The only significant sex differences
pertained to the right (P 5 0.003) and left (P \0.001)
first premolars, with female subjects exhibiting more
recession than male subjects. There also was no consis-
tent difference between nonextraction and premolar
extraction patients. Only the right (P 5 0.050) and left
(P 5 0.012) mandibular central incisors showed signifi-
cant differences, with extraction patients exhibiting
more recession.
Due to the lack of statistically significant differ-
ences, gingival recession was evaluated with the various
groups combined (Table III). At T2, the 25th, 50th, and
75th percentiles for gingival recession were all zero. At
T3, approximately 25% of the subjects had 0.6 mm or
more recession on the mandibular central incisors and
the maxillary first premolars. Approximately 25% of
the population had 0.3 mm or less recession on the
other teeth.
With 2 measurements of incisor position and 4 inci-
sors, there were 8 possible associations. Only recession of
the mandibular left lateral incisor and L1-NB were

May 2017  Vol 151  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Morris et al 855

No Recession 0.1-1 mm > 1 mm

Mn 1

Mn 2

Mx 4

Mx 5

Mx 6

0 10 20 30 40 50 60 70
%

Fig 3. Percent of cases with and without posttreatment (T2-T3) recession of the mandibular (Mn) in-
cisors and maxillary (Mx) premolars and first molars. 1, central incisor; 2, lateral incisor; 4, first premo-
lar; 5, second premolar; 6, first molar.

recession were statistically significant, but they were

Table III. Amount of gingival recession at the long-
low and exhibited no obvious pattern.
term follow up (T3), with right and left sides combined
Teeth DISCUSSION

Recession Mn 1s Mn 2s Mx 4x Mx 5S Mx 6s There was only minimal recession at T2. Approxi-

(mm) (%) (%) (%) (%) (%) mately 18.3% of the patients demonstrated gingival
25%tile 0.0 0.0 0.0 0.0 0.0 recession (of at least 1 tooth) at T2, and only 5.8% of
50%tile 0.0 0.0 0.0 0.0 0.0 the teeth exhibited recession. Slutzkey and Levin32
75%tile 0.6 0.3 0.6 0.2 0.3
found that 22.9% of orthodontic patients had gingival
Mn, Mandibular; Mx, maxillary. recessions after treatment; Renkema et al29 noted that
only 6.6% of treated patients had gingival recessions.
In our study, recession was assessed on color slides,
significantly related (R 5 0.279; P 5 0.011). The rela- whereas Renkema et al evaluated recession on plaster
tionship between recession of the mandibular left lateral casts. Assessment of recession on intraoral slides has
incisor and IMPA changes approached significant levels previously been shown to be the preferred method
(R 5 0.211; P 5 0.057). There were no statistically sig- because of many unreadable teeth on plaster casts.22
nificant differences in incisor recession between the 74 The higher prevalence noted by Slutzkey and Levin could
subjects with T2 IMPA measurements of 95 or greater be explained by the fact that they evaluated recession at
and the 125 patients whose posttreatment IMPA mea- 18 to 22 years of age, which is older than the average age
surement was less than 95 , even though the mean an- at T2 in our sample (16.5 years).
gulations differed by approximately 20 and the The prevalence of recession after orthodontic treat-
maximum IMPA was 107 . ment in this study was similar to or slightly less than pre-
There were statistically significant positive correlations viously reported for untreated samples. Ainamo et al30
between expansion of the maxillary premolars and first reported that 8.7% of teeth in untreated 17-year-olds
molars and posttreatment recession (Table IV). Eight of had recessions, compared with 5.8% in our study. Susin
the 16 possible correlations between the 3 arch width et al31 noted recession on 2.9% of teeth of untreated 14-
treatment changes and the 6 posttreatment changes in to 19-year-olds, but they only recorded recession if it

American Journal of Orthodontics and Dentofacial Orthopedics May 2017  Vol 151  Issue 5
856
Table IV. Correlations between posttreatment recession and maxillary arch width changes during treatment
First premolar
Recession Right P Right
Maxillary right first molar 0.202 0.035
Maxillary right second premolar 0.233 0.015
Maxillary right first premolar 0.306 0.003
Maxillary left first premolar 0.093 0.203
Maxillary left second premolar 0.063 0.283
Maxillary left first molar 0.212 0.029
was 1 mm or greater. In this study, only 0.6% of teeth
exhibited 1 mm or more recession, suggesting that the
amount of recession observed immediately after treat-
ment was not caused by orthodontic treatment (ie, it
was age related).
Substantially greater amounts of recession occurred
during the 15.8 years that the patients were followed af-
ter orthodontic treatment. At approximately 32.3 years
of age, 55.7% of the patients in this study demonstrated
gingival recession on at least 1 tooth, and 41.7% of all
teeth had recessions. Renkema et al29 did not record
the severity of recession in their study but noted that
37.7% of their sample had recessions on at least 1 tooth
5 years after orthodontic treatment. Their lower preva-
lence may be explained by their different methodology
for recording recession and their shorter follow-up dura-
tion (5 vs 16.5 years). Importantly, the amount of post-
treatment recession observed in this study was not
severe. Only 7% of the teeth had more than 1 mm of
recession. Focusing only on the mandibular incisors of
treated patients, Allais and Melsen22 noted recessions
of 0.5 mm or more on 26.1% of teeth (average age,
33.7 years); this was similar to the 25.4% we observed.
Considering the extent of recession, Thomson33 showed
that in treated patients, 6.9% of the teeth exhibited re-
cessions of 1 mm or more at age 26; this compared
closely with the 7% of the teeth identified in our study.
The increases in recession observed after orthodontic
treatment appear to be largely age related. Using data
representative of the United States population (NHANES
III), Albander and Kingman34 showed that the prevalence
and extent of recession among untreated subjects in-
creases steadily with age, regardless of the threshold
used (ie, 0 mm, 1.0 mm, and so on). Approximately
38% of the subjects in their youngest age cohort (30-
39 years) had gingival recession on at least 1 tooth,
and 8.6% of teeth exhibited at least 1 mm of recession.
This is slightly less than in our study, but the extent of
recession was slightly greater. Methodologic differences
could again explain the discrepancy, because they
measured recession during a clinical examination, which
may be less sensitive than measuring recession on color
May 2017  Vol 151  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Morris et al
Second premolar First molar
P R P
0.173 0.026 0.182 0.008
0.141 0.052 0.086 0.121
0.354 0.002 0.135 0.109
0.407 \0.001 0.090 0.204
0.081 0.179 0.076 0.153
0.063 0.240 0.094 0.110
photographs that can be enlarged and manipulated.
Susin et al,31 who evaluated a representative untreated
sample from Brazil, also demonstrated significant in-
creases in the prevalence and extent of recession with
age. Approximately 96% of the subjects in their 30 to
39-year-old cohort demonstrated gingival recessions
on at least 1 tooth, and 44.3% of teeth had recessions
of 1 mm or more, both of which are much higher than
our study. Untreated reference data clearly show signif-
icant increases in recession as subjects age, and most of
the posttreatment increases in recession observed in our
sample were most likely normal aging effects.
The recession that occurred on the incisors was also
largely age related. The NHANES III data34 demonstrated
that 19.7% of mandibular central incisors and 13.2% of
lateral incisors had recessions of 1 mm or more in per-
sons 30 to 55 years old. This compares favorably with
our results, where the central incisors showed recessions
equal to or greater than 1 mm 10.3% of the time, and the
lateral incisors 3.9% of the time. The lower prevalence in
this study can be explained by the younger age
(32.3 years on average) of the sample.
Posttreatment gingival recession was greater for the
mandibular central incisors than the lateral incisors.
Compared with the lateral incisors, the prevalence of
recession on the mandibular central incisors was
15.8% more, and the extent of recession ($1 mm) was
6.4% more. Ruf et al21 showed that the prevalence of
recession on the central incisors of treated patients
was 11.2% more than the lateral incisors, whereas Re-
nkema et al29 noted that it was approximately 6%
greater. The central incisors have been shown to have
higher prevalences of recession in untreated samples as
well. Among 30 to 55-year-olds, the prevalence of reces-
sion greater than 1 mm was 6.5% more for the central
incisors than lateral incisors.34 Susin et al32 reported
an 8% difference in recession of 1 mm or more among
untreated 14 to 30-year-olds. It has been hypothesized
that the difference is due to the more limited thickness
of facial bones adjacent to the roots of the central inci-
sors than the lateral incisors.35,36 The increased
prevalence of recession on the central incisors does not
Morris et al
appear to be related to differences in the thickness of the
gingiva, because gingival thickness just apical to the
base of the pocket on the central and lateral incisors is
not significantly different in young adults.37
Importantly, the amount of mandibular incisor procli-
nation during treatment was not related to the develop-
ment of gingival recession. Although some authors have
postulated an association, the results of this study, as well
as others show no associations between recession and pro-
clination.21-24,38 Interestingly, animal experiments have
demonstrated little or no recession over the short term on
excessively proclined teeth, despite the development of
bony dehiscences.17-19 Only 1 clinical study investigating
the long-term relationship between proclination and reces-
sion reported a relationship.27 However, their sample was
composed of adults who underwent surgery for mandibular
prognathism. In our study, as well as another showing no
relationship,24 the incisors that were proclined the most
during treatment were those that were more upright before
treatment; this may obscure a relationship.
The lack of association has led some authors to
postulate that the final mandibular incisor position
may be more closely associated with long-term recession
than the amount of proclination during treatment.26
However, we showed no difference in recession between
subjects whose final IMPA was greater than 95 and
those whose incisors finished at 95 or less. Renkema
et al39 also found no difference in recession 5 years after
treatment between patients with an average final IMPA
of 90.8 and another group who finished at 105.2 . In
contrast, Yared et al26 reported more recession among
patients whose final IMPA was greater than 95
compared with those who finished treatment at 95 or
less, but their results were statistically significant for
only the right central incisor. Moreover, their patients
were older at the start of treatment18-27,29-34; this is
important because the ability of the periodontium to
withstand orthodontic treatment appears to decrease
with age.29 The discrepancies among studies may also
be because IMPA only measures changes in inclination;
it does not measure whether the incisors were protracted
or retracted. Depending on tooth movements into labial
bone, bone thickness may play a larger role in recession.
In contrast to incisor proclination, recession of the
maxillary posterior teeth is related to the amount of expan-
sion that occurs. In our study, the posterior segments were
expanded with either archwires or rapid palatal expanders.
Animal studies have previously demonstrated develop-
ment of buccal bone dehiscences after posterior expan-
sion.19,40 In orthodontic patients, buccal dehiscences in
the maxillary arch have been demonstrated after
archwire expansion,41 as well as rapid and slow maxillary
expansion.42 Within a year after treatment, small but
American Journal of Orthodontics and Dentofacial Orthopedics
857
significant losses of attachment on the maxillary posterior
teeth have been reported for patients who underwent rapid
palatal expansion compared with those who did not.43,44
Longer-term studies have also indicated a relationship be-
tween expansion and recession.45
The quantity of the hard and soft tissues adjacent to
the posterior maxillary teeth may play an important role
in the development of recession. Thicker gingival tissue
has been reported buccal to the maxillary second premo-
lars than the first premolars and molars; this may impart
some resistance to recession on the second premolars.37
This is important because thin gingival tissue (thin
biotype) is more prone to recession.26,38 Additionally,
buccal bone has been shown to be thinner adjacent to
the first premolars than to the other maxillary posterior
teeth.46-48 In this study, the maxillary first premolars
were expanded the most; this is typical in patients who
have maxillary expansion.41,49 The first premolars also
exhibited the highest prevalence and extent of recession,
which agrees with other treated samples,29 but differs
from untreated samples.31,35 Therefore, a treatment
effect seems likely, considering the different patterns of
recession seen in the maxillary arch between treated and
untreated samples.
Treated and untreated samples exhibit different pat-
terns of posterior maxillary recession. Our sample, as well
as other treated samples, showed that the maxillary first
premolars had the most recession.17,19 However, most of
the recession was minor, with 1 mm or more occurring
only 7.7% of the time. Renkema et al29 reported sub-
stantially more recession of the maxillary first premolars
5 years after treatment than of the second premolars or
first molars. In contrast, the maxillary first molars of un-
treated subjects exhibit more recession than the premo-
lars.31,34 For example, Albander and Kingman34
demonstrated that the first molars of subjects 30 to
55 years old exhibited slightly more recession (0.8%)
than did the first premolars and substantially more
(9%) than the second premolars. Susin et al31 showed
maxillary first molar recession approximately 26% of
the time in subjects 30 to 49 years old, whereas the first
premolars had recession only 15% of the time. Thus, at
least some of the recession on the second premolars in
our study must have been treatment related.
Finally, this study is potentially biased because of
its inability to fully control the sources of variation
that influence gingival recession. For example, the
morphometric parameters necessary to determine
the patients’ biotypes could not be measured. In
addition, it was not possible to determine whether
the patients had dehiscences, which also could have
influenced the results. Moreover, the patients came
from 2 orthodontic practices that might not have
May 2017  Vol 151  Issue 5
858
been representative. Prospective, longitudinal studies
are necessary to impose the proper control and ensure
unbiased results.
CONCLUSIONS
Within the limits of this study, orthodontic treatment
does not appear to be a risk factor for the development
of gingival recessions.
1. Only minimal amounts of gingival recession were
evident immediately after orthodontic treatment.
2. Gingival recession increased between T2 and T3;
however, the amount of recession was not severe.
3. There was no relationship between the amount of
mandibular incisor proclination during treatment
and the amount of gingival recession either during
or after treatment.
4. There was a weak association between the amount
of maxillary expansion during treatment (T1-T2)
and the posttreatment (T2-T3) gingival recession.
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