Gingival Recession: Clinical Examination

and Diagnostics 4
Corinna Bruckmann and Gernot Wimmer

Abstract
This chapter offers a practical approach to the diagnostic process in everyday
dental practice. Gingival recessions are highly prevalent, and presence and extent
increase with age.
When regression of the gingival margin is noticed, a structured diagnostic
process of information gathering should be initiated. As gingival recessions
might have several aetiologies, it is of utmost importance for the practitioner to
be able to compile anamnestic, clinical, and radiologic signs and symptoms, as
well as laboratory information. This process allows for differential diagnoses of
possible underlying reasons and the decision-making in respect to future treat-
ment options or necessities. The assessment of tissue dimensions is necessary to
qualify, quantify, and monitor changes during periodontal, restorative, prosthetic,
orthodontic, or implant therapy or lifelong maintenance. The practitioner shall be
enabled to recognize underlying predisposing and precipitating causes for gingi-
val recessions, evaluate possible risk factors, assess potential for progression,
and build a solid base for further decision-making.

C. Bruckmann, M.D., M.Sc. (*)

Division of Conservative Dentistry and Periodontology, School of Dentistry,
Medical University of Vienna, Vienna, Austria
e-mail: [email protected]
G. Wimmer, M.D., Ph.D.
Department of Dentistry and Maxillofacial Surgery, Division of Prosthodontics, Restorative
Dentistry and Periodontology, Medical University of Graz, Graz, Austria

© Springer International Publishing AG, part of Springer Nature 2018 33

A. Kasaj (ed.), Gingival Recession Management,
https://doi.org/10.1007/978-3-319-70719-8_4
34 C. Bruckmann and G. Wimmer

For definitions refer to Chap. 1.

4.1 Chief Complaint, Specific Reason for the Visit or Referral

Get to know your patient: Make sure you understand the patient’s demands, expec-
tations, and fears. Miscommunication in the very beginning of a therapeutic rela-
tionship may cause future troubles and even elicit legal consequences.

• What is the patient’s chief complaint?

Note: Many patients complaining of receding gums do in fact fear future tooth loss.
• Is the patient in pain, and is tooth/root sensitivity reported?
• How relevant or important are any aesthetic problems subjectively? Is there com-
plaint of “a toothy smile”/tooth discoloration/black triangles?
Note: For evaluation of subjective items, use of a visual analogue scale (VAS)
may be useful [1].
• Was the problem noticed by the patient himself, or was he made aware of it?
• Is the onset of recession acute, or is the history of complaint longstanding?
Is there (documented) progression? What is the time frame of progression? Note:
Patients who were made aware of a problem sometimes report it as if it had
happened “overnight”.

4.1.1 Medical History

Background: Several systemic diseases and conditions are associated with oral signs
and symptoms [2], and many drugs are known to modify gingivitis/periodontitis [3].
Diabetes mellitus is an important risk factor for periodontal inflammation if poorly
controlled. Last but not least, age, hormonal changes (e.g. puberty, pregnancy, meno-
pause), and stress (at work, financial, domestic, etc.) influence oral tissues. Make
sure that reported diseases and medications do correspond. Regular alcohol use may
have a negative impact on either periodontal tissues and/or adherence to treatment.
Of particular importance for the evaluation of gingival recessions are the following:

• Tobacco use (duration, daily consumption): Very important for the diagnostic
process (less overt bleeding), risk for recession, and healing response [4].
• Dietary habits: Increased risk for caries on denuded root surfaces? Erosive poten-
tial of diet (hypersensitivity, abrasion) [5]?
• Recreational drugs (cocaine, meth, smokeless tobacco, bethel nut, etc.) either
have direct local influence on oral tissues, are a risk factor for caries (by dimin-
ishing saliva flow), or induce negligent behaviour [6].
4  Gingival Recession: Clinical Examination and Diagnostics 35

4.1.2 Dental History

Comprehensive exploration is desirable as past (dental) treatment may be the reason

of today’s problems. Old radiographs and/or photographs and/or casts are useful for
judging progression.

• Orthodontic treatment in the past may be the reason for present recessions.
• Oral appliances (removable partial dentures/denture clasps, occlusal splints,
removable orthodontics, anti-snoring mouthpieces, etc.) may impinge on peri-
odontal tissues.
• A history of periodontitis, or necrotizing ulcerative gingivitis/periodontitis
(NUG/NUP), or (mechanical/chemical) trauma may explain loss of soft and/or
hard tissue attachment, especially interdentally [7].
• Periodontal treatment or surgical procedures may have caused soft tissue
recessions.
• Aesthetic dentistry/splinting/filling on anterior teeth may have been used to mask
tooth drifting/pathological migration/recessions.
• Oral (hygiene) habits
–– Oral hygiene aids, toothpastes and mouth rinses, frequency/duration of use
–– Nail biting /pen chewing/factitious lesions [8]

4.2 Clinical Examination

Unfortunately, in times of advanced imaging methods, this procedure is sometimes

insufficiently utilized. However, to rule out other pathology, it should be performed
thoroughly. Make use of adequate illumination, dry areas of interest with suction/
compressed air, and inspect and palpate the tissues. Especially in cases of progres-
sive recessions and reported pain, any inflammatory process must be excluded.
Systemic diseases may manifest in the oral cavity. Acute painless lesions are always
suspicious for malignancy. Soft tissues of the muscles, cheeks, tongue, salivary
glands, floor of the mouth, back of the throat, and tonsils should therefore be
included in a systematic examination. All patients should be screened for periodon-
tal disease [9].
Assess factors and their relevance for present soft tissue and/or bone loss, and
identify predisposing and precipitating conditions (those easily modifiable are
marked with an asterisk*) that need to be addressed during future patient manage-
ment (Table 4.1). Determination of the periodontal biotype, defined by parameters
such as gingival thickness (GT), tooth dimension (TD), amount of keratinized
tissue (KT), and bone morphology, is of importance for tissue and patient man-
agement [14].
36 C. Bruckmann and G. Wimmer

Table 4.1  Predisposing and precipitating factors for recessions, adapted from [10–13]
Predisposing factors Precipitating factors
Tooth (mal)position/tipping *Plaque, plaque-induced inflammation:
  Gingivitis, periodontitis
Gingival biotype *Calculus
   Thin tissue
  Functionally inadequate quantity/quality of
keratinized/attached gingiva
Frenum pull/muscle attachment/muscular *Trauma: mechanical, chemical, thermal
dysbalance/shallow vestibulum   Smoking
  Overzealous toothbrushing/flossing
  Piercings
  Habits
  Deep bite
Bone dehiscence Iatrogenic:
   Orthodontic tooth movement
   Subgingival restoration margins
  Oral surgery
  Ill-fitting restorations/prostheses

4.2.1 Aesthetic Assessment

Caveat: Objective and subjective findings do not necessarily have to correspond, as

a significant correlation between neuroticism and general satisfaction with face and
body appearance has been found [15]. Still, basic assessment of harmony and sym-
metry should be undertaken and documented. Facial symmetry, angle class relation,
occlusion, dysgnathia, and lip framework at rest, in function, and during smile are
important parameters of red/white aesthetics to be taken into account. Although the
extent of soft tissue display during a smile is not the most important aesthetic issue,
the way the soft tissues are arranged relative to the teeth and lips is of concern in
respect to facial aesthetics: A high lip line draws more attention to an uneven gingi-
val contour [16].

4.2.2 Mucosa

Inspect for adequate lubrification, pigmentation, any lesions, or growths. Aphthous

lesions are often seen secondary to medication (e.g. non-steroidal anti-­inflammatory
drugs), stress, or Behçet syndrome. Colour changes [17]: pallor can be present with
anaemia, while pigmentation can be associated with ethnicity, tobacco, dietary
intake, medications, diseases, or syndromes. Haematomas, varices, and petechiae
appear to be pigmented. Diffuse swelling and cobblestone mucosa may be seen
even before intestinal symptoms in Crohn’s disease patients.
Special attention should be given to:

• Depth of vestibulum: adequate space for oral hygiene procedures.

• Frenula: possible frenum pull at place of insertion.
4  Gingival Recession: Clinical Examination and Diagnostics 37

• Scar tissue might exert tension.

• Piercings: position of the intraoral disc in relation to the gingiva [18].

4.2.3 Gingiva

Check for gingivitis and periodontitis; assess colour, contour, texture, and swellings. Is
the colour consistent with the patient’s intraoral pigmentation and skin complexion
(mucogingival disorders, amalgam tattoos, malignoma)? Gingival enlargement/over-
growth may be drug-associated; desquamative gingivitis is often seen with lichen planus,
systemic lupus erythematosus, pemphigus, pemphigoid, and lichenoid reactions [19].
Assess the periodontal biotype [20]: As visual inspection alone is not reliable
enough to judge gingival thickness [21], the gingiva should be described based on
the observation of the periodontal probe shining through [22]. Note that the biotype
may differ between the lower and upper jaw within the same patient [23].

• Gingival biotype (Fig.  4.1a–d) [24, 25]: Categorize according to visibility of

periodontal probe after insertion into the facial sulcus.
–– Thin scalloped: association with triangular-shaped crown, subtle cervical con-
vexity, interproximal contacts close to incisal edge, narrow zone of KT, thin
delicate gingiva, and relatively thin alveolar bone (Fig. 4.1a)
–– Thick scalloped: associated with slender teeth, thick fibrotic gingiva, narrow
zone of KT, and a high gingival scallop (Fig. 4.1b)
–– Thick flat: associated with more square-shaped tooth crowns, pronounced
cervical convexity, large interproximal contact located more apically, broad
zone of KT, thick, fibrotic gingiva, and thick alveolar bone (Fig. 4.1c)
• Width of keratinized (attached and free) tissue/gingiva (in case of implants, i.e.
mucosa) (KT)
–– Rolling test: see Fig. 4.2a.
–– Staining test: with Lugol’s iodine solution [26]; check medical history for
allergy/thyroid issues; see Fig. 4.2b.
• Width of attached tissue: subtract PPD from width of KT (= KT−PPD)
• Width of KT tissue at neighbouring teeth
• Soft tissue margin level: alterations in gingival morphology, irregularities?
–– Draw a line connecting the most apical points of the facial aspect at the mid-
facial level of the soft tissue margins at adjacent teeth.
–– Inconsistent heights of gingival margins in comparison with neighbouring
teeth (Fig. 4.3a); incomplete or delayed/altered passive eruption (Fig. 4.3b).
• Interdental papilla
–– Presence or absence: loss due to periodontal disease, missing contact point
(Figs. 4.3a and 4.4a), or tooth position next to edentulous area
–– Classification of papilla height (distance between the tip of the papilla to a
line connecting the midfacial level of the soft tissue margin of two adjacent
teeth [27]) after identifying anatomical landmarks: interdental contact point
(iCP), facial apical/buccal extent of the cemento-enamel junction (fCEJ), and
interproximal/coronal extent of the CEJ (iCEJ)
38 C. Bruckmann and G. Wimmer

Nordland and Tarnow [28]: normal papilla (fills embrasure space to the apical
extent of the iCEJ); class I (tip of papilla between iCP and most coronal
extent of iCEJ); class II (tip of papilla at or apical to iCEJ but coronal to the
apical extent of fCEJ) (Fig. 4.3a); class III (tip of papilla level with or api-
cal to fCEJ) (Fig. 4.6a)
• Cardaropoli et al. [29]: Papilla Presence Index (PPI) 1–4 (Figs. 4.3a and 4.4a)

c
Fig. 4.1 (a) Thin-­
scalloped biotype,
periodontal probe shining
through delicate free
gingiva, PPD 1 mm; note
location of papilla tips due
to natural diastemas and
recessions mostly at teeth
with buccal position; (b)
thick-scalloped biotype; (c)
thick-flat biotype with
broad band of keratinized
tissue, thick, fibrotic
gingiva
4  Gingival Recession: Clinical Examination and Diagnostics 39

a b

Fig. 4.2 (a) Rolling test: softly push the adjacent mucosa coronally with a periodontal probe to
identify width of the blanching attached gingiva/tissue. (b) Staining test with Lugol’s iodine: gly-
cogen containing mucosa stains brownish in contrast to orthokeratinized gingiva

a b

Fig. 4.3 (a) Irregular gingival scallop due to developmental enamel indentation #11, loss of cen-
tral papilla height (class II (Nordland and Tarnow), PPI 3 (Cardaropoli et al.)); (b) inconsistent
height of gingival margin (incomplete eruption of #32, #42, recession in #31)

• Gingival thickness
–– Transgingival probing: After local anaesthesia a periodontal probe or a needle is
pierced vertically to the mucosal surface (optionally a silicone disc can be placed
to facilitate reading of the measurement) until resistance of the bone is felt [30].
–– Ultrasonic pulse-echo [31]: SDM® (Krupp Corp., Essen, Germany; manufac-
turing discontinued)
• Aberrant frenal insertions: Ankyloglossia? Blanching? (Fig. 4.4a–d)
• Oral hygiene-induced or self-induced lesions
–– Stilman’s clefts? Incomplete (red) or complete (white) lesions [32],
(Fig. 4.5a–c)
–– McCall’s festoons
–– Gingival erosions (Fig. 4.5d)

4.2.4 Periodontal Assessment

Make use of a periodontal probe with millimetre markings (e.g. North Carolina,
UNC-15, Williams). Assess gingival inflammatory status. Gently run the periodon-
tal probe around the gingival margin area at the dentogingival junction: No bleeding
40 C. Bruckmann and G. Wimmer

a b

c d

Fig. 4.4 (a) Buccal position of #31 and #41 and gingival recession, very thin zone of KT, frenum
pull, blanching, missing contact point, low interdental central papilla (PPI 4 (Cardaropoli et al.);
(b) irregular frenum, frenum pull at #13 with blanching; (c) irregular frenum, lingual position of
#41, lingual recessions, persistent lingual frenum; (d) irregular frenula, buccal recessions #22–25,
cervical abrasions #23, frenum pull and blanching in #23 and #24, possible plaque niche # 24 distal
of frenum insertion

a b

c d

Fig. 4.5 (a) Red Stilman’s cleft at distobuccal root of #27 (note buccal malposition); (b) buccal
malposition of #45, loss of buccal soft (red Stilman’s cleft) and hard tissue, due to overzealous
toothbrushing (however, note insufficient plaque control interdentally); (c) generalized buccal
recession and abrasions, white Stilman’s clefts #12 and #34; (d) gingival erosion due to self-­
inflicted trauma (brushing and flossing) #33, red Stilman’s cleft #32
4  Gingival Recession: Clinical Examination and Diagnostics 41

a b

c d

Fig. 4.6 (a) Healthy (in #12 and #11 reduced) periodontium (note circumferential recession, loss
of interdental papilla due to past periodontal disease/treatment), incomplete eruption of #13,
papilla height class III between #12 and #11 (Nordland and Tarnow), (b) assessment of width, and
(c) height of recession making use of a periodontal probe or (d) a caliper (note extremely thin
blanching buccal tissue in #31)

correlates with healthy conditions. Note: In heavy smokers there might be dimin-
ished bleeding.

• Exposure of tooth root surface visible: gingival recession (REC) (i.e. “location of
the gingival margin apical to the cemento-enamel junction” [33]). This might be
a result from apical migration of either uninflamed gingival tissues with normal
bone levels or in the case of periodontal bone loss, or as a combination of both.
–– Location: facial/oral or proximal?
–– Note: If interproximal recessions are visible, circumferential loss of attach-
ment is present (Fig. 4.6a).
–– Single/multiple?
• Identification of the CEJ: in healthy situations normally not visible, as covered
by free marginal gingiva [34] (Chap. 1, Fig. 1.1)
–– Tactile approach with 45° angulated probe: beware of diagnostic pitfalls such
as with cervical abrasions, restorations, rotated teeth, and incompletely
erupted teeth (delayed and altered passive eruption) [35].
–– Compare with neighbouring teeth (incomplete eruption; Fig. 4.3b) or estimate
if CEJ is no longer visible/obliterated (Fig. 4.9a–c).
• Extension of recession (REC)
–– Recession depth: distance free gingival margin (FGM) to CEJ (Chap. 1,
Fig. 1.1, Fig. 4.6b)
Apical border within or beyond the MGJ?
42 C. Bruckmann and G. Wimmer

–– Recession width (measured at most coronal part) (Fig. 4.6c, d)

• Probing pocket depth (PPD): distance FGM to bottom of sulcus/pocket; use stan-
dardized gentle probing force (0.25 N), probe angulation 0–10°
–– Guide probe along root surface until first resistance of the gingival connective
tissues is met, “walk probe” around tooth, measure deepest measurement at 6
sites (3 b, 3  l) to the nearest millimetre. Record measurements as positive
numbers if apical of CEJ; when the gingiva is extending above the CEJ, record
as negative numbers (Fig. 4.7).
• Clinical attachment level (CAL) = REC + PPD.
• Assess bleeding on probing (BoP) or exudation within 30 seconds after probing
as they are signs of inflammation.
• In molars assess presence, location, and extent of furcations [36].

4.2.5 Teeth

Check for patient’s oral hygiene (plaque, supra-/subgingival calculus) and anatomi-
cal features such as furcations, grooves, enamel projections, concavities (Fig. 4.3a),
and resorptions. Determine tooth/root position, CEJ, and tooth form: Tooth form
determines the most apical point of the contact area and has been found to correlate
with the extent of the keratinized tissue KT, its bucco-lingual gingival thickness
(GT), as well as height of the interdental papilla [37]. Furthermore it is a predictor
for gingival and buccal alveolar bone thickness [38].

• Tooth form [39]

–– Square: associated with thick-flat tissue, large interproximal contact located
more apically, a broad zone of KT, thick, fibrotic gingiva, and a comparatively
thick alveolar bone

a b

Fig. 4.7 (a) Buccal position/rotation of #31, root proximity #31/32, interdental and buccal reces-
sions up to 5 mm in 5th sextant, PPD up to 5 mm, CAL up to 10 mm (#31); (b) periapical radio-
graph of #31/21 with bone loss of more than 2/3 of the root length
4  Gingival Recession: Clinical Examination and Diagnostics 43

a b

Fig. 4.8 (a) Multiple misalignments of front teeth in all three planes; (b) same case as 4.6b–d:
buccal malposition of #31 (Miller class I recession), #41 (Miller class II recession), minimal zone
of keratinized attached gingiva, marginal gingivitis in #41

–– Square-tapered: higher interproximal papilla, less keratinized tissue, and thin-

ner bucco-lingual GT than patients with square teeth
–– Triangular: association with higher interproximal papilla, less keratinized tis-
sue and thinner bucco-lingual GT, and a relatively thin alveolar bone
• Tooth (mal)position in the arch in three planes: rotated, tilted, displaced, and
incompletely erupted (Figs. 4.1a, 4.4a, c, 4.5b, 4.7a, and 4.8a, b)
–– Vertical (apical-coronal): cervical portion apical or coronal of the FGM of
adjacent teeth (Fig. 4.8a)
–– Sagittal (buccal-lingual): variability of gingival thickness and underlying
bone plate (Fig. 4.8b)
–– Horizontal: crowding, rotation (Fig. 4.8a)
• Caries and non-carious tooth substance loss (erosive/abrasive lesions,
Fig. 4.9a [40])
–– For identification of the former CEJ, try to compare with adjacent teeth
(Figs. 4.5c and 4.9b).
• Hypersensitivity of root surface?
• Sensitivity to thermal testing: pulpal pathology
• Mobility: horizontal and/or vertical (check with handles of two instruments)
–– Signs of occlusal trauma: wear facets, attrition
–– Loss of periodontal support

4.2.6 Restorations/Appliances

Assessment of fixed or removable appliances should reveal any trauma to soft or

hard tissues due to impingement, plaque accumulation, or exertion of torque.

• Pre-existing conditions/restorations (class V fillings): Identify former CEJ

(Fig. 4.9a–c)
• Overhanging/retentive margins
44 C. Bruckmann and G. Wimmer

Fig. 4.9 (a) Visualization

of amount of non-carious a
buccal tooth substance loss
#26, buccal restoration
#23 exceeding the CEJ;
(b) buccal non-carious
tooth substance loss,
assessment of CEJ in #13,
23, 34, and 33 is only
possible in comparison
with adjacent tooth/crown
margins; (c) multiple
recessions first quadrant up
to 8 mm (#13), buccal
dentinal abrasions

• Clasps, bands, etc.

• Non-passive orthodontic retainers
• Piercings (Fig. 4.10)
4  Gingival Recession: Clinical Examination and Diagnostics 45

a b

Fig. 4.10 (a) Tongue piercing; (b) lingual gingival recession at the opposed tooth #41

4.3 Radiographic Assessment

Single facial/oral recessions might not necessarily need radiographic assessment.

However, as soon as (surgical) treatment is considered, additional information is
warranted. Radiographs for periodontal diagnosis require a longer scale of contrast
compared with caries detection, which can be achieved digitally after image acqui-
sition before interpretation [41]. To obtain correct image geometry, a paralleling
technique must be used.

4.3.1 Periapical Radiograph

• Root morphology and crown-to-root ratio

• Periodontal ligament (PDL) space:
–– Widening of the PDL: sign of occlusal trauma or periapical pathology
–– Bone hyperdensity of lamina dura: sign of functional adaptation to occlusal
forces
–– Loss of PDL: sign of ankylosis
• Root proximity: possible risk factor for periodontal disease (Fig.  4.7b), might
have influence on treatment options [42]
• Furcation involvement: separation coefficient, length of root trunk

4.3.2 Bitewing Radiograph

Due to the perpendicular visualization of the teeth, it is ideal for reliable assessment
of the alveolar crestal bone [43] and diagnosing caries/restorations.

• Distance of CEJ to interdental bone crest

–– 2 mm: crestal bone loss?
“Fuzziness” on the mesial/distal aspect of the interdental septa indicating loss
of mineral content?
46 C. Bruckmann and G. Wimmer

CEJ discrepancies of adjacent teeth: horizontal or vertical type of bone loss?

Interradicular radiolucencies might indicate possible furcation involvement.
–– < 2 mm: incomplete eruption?
• Distance of interproximal alveolar crest to contact point: influence on presence
(≤5 mm) or absence (>5 mm) of interdental papilla [44]
• Calculus/caries/overhanging or open margins/resorptions?

4.3.3 Panoramic Radiograph

Allows for a general overview of the patient’s maxillofacial structures: bone loss
pattern (horizontal and/or angular, furcation involvement), impacted teeth, periapi-
cal pathologies, etc. Any deviations from normal warrant further intraoral
radiographs.

4.3.4 Cone Beam Computed Tomography

Overcoming the limitations of two-dimensional radiographs CBCT is the only

method that allows for an analysis of the buccal and lingual/palatal surfaces [45, 46]
and an improved visualization of the morphology of a periodontal defect, especially
in the evaluation of dehiscencies, fenestrations (Fig. 4.11a, b), interradicular bone
(Fig. 4.12), and furcation defects [47]. A novel approach using a lip/tongue retractor
allows for visualization and measurement of the periodontal dimensions, gingival
thickness, and the dentogingival attachment [48].

a b

Fig. 4.11 (a) Bony dehiscence (right tooth), fenestration (left tooth), and thin buccal plate predis-
pose to gingival regression; (b) bony fenestration and protrusive root
4  Gingival Recession: Clinical Examination and Diagnostics 47

a b

Fig. 4.12 (a) Thick periodontal biotype, buccal position of #31, clinical signs of inflamed gin-
giva, 1.5 mm buccal recession, loss of interdental papilla, PPD 5 mm on mesial aspect, high fre-
num insertion #41; (b) CBCT of area of interest #31: note demineralized interdental bone

4.4 Data Collection and Documentation

Federal medico-dental jurisdiction warrants adequate documentation: All relevant

clinical findings are archived in a suitable patient record that allows for establishing
a baseline and tracking for any changes during the course of treatment/maintenance.
Traditional clinical assessment of obvious dental problems is to be accompanied by
general medical and psychosocial information [49]. Standardized photographs and
dental casts may serve as longitudinal controls [50, 51]. For written documentation
of facial recessions, special charts have been developed [12, 52].

Conclusions
The above-mentioned steps in assessment of patients presenting with gingival
recessions offer a very comprehensive approach. If the diagnosis can be made
straightforward the application of every mentioned step might not be necessary.
However, if doubts about causative factors remain, a structured diagnostic pro-
cess should be initiated (see Box 4.1).

Box 4.1: Important Steps for Assessment of Gingival Recessions

Visual:
Localized/generalized
Tooth (position in the arch/root torque; hard substance defects, restorations,
pulpal status, etc.)
Mucogingival region/vestibulum: frenula, depth, aberrations, etc.
Measurements (with periodontal probe):
Overall periodontal assessment
Determining gingival biotype
Gingival recession (identification or estimation of CEJ)
48 C. Bruckmann and G. Wimmer

Width of keratinized gingiva/mucosa (amount of attached gingiva/mucosa;

staining with Schiller iodine solution)
Soft tissue margin level (in comparison to the adjacent teeth)
Papilla height
Transgingival probing
Measurements of gingival thickness and contour and bone:
Transgingival probing (ultrasound)
Oral photography
Dental casts
Radiographic bone loss and soft tissue determination (X-ray, ST-CBCT)

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