Stillman’s Cleft: An In-Depth Overview

Stillman’s cleft is a distinctive periodontal condition characterized by a localized, narrow, and often V-shaped recession or notching of the gingival margin.

First described by Stillman in 1921, this lesion typically manifests as a localized loss of the interdental gingival papilla with a characteristic cleft or slit-like appearance extending apically.

Though it may appear similar to other forms of gingival recession, the etiology, clinical features, and management of Stillman’s cleft warrant special consideration.

Definition

Stillman’s cleft refers to a localized gingival recession presenting as a sharp, narrow, and sometimes triangular notch in the gingiva near the interdental papilla.

Unlike generalized marginal gingival recession, Stillman’s cleft is typically confined to a small area and presents with a distinctive cleft or fissure in the marginal gingiva, often located on the facial aspect of anterior teeth.

Etiology and Causes

The exact cause of Stillman’s cleft remains somewhat unclear; however, several contributing factors have been proposed:

1. Trauma to the Gingiva: One of the most commonly cited causes is mechanical trauma, particularly from aggressive tooth brushing techniques such as horizontal scrubbing or using a hard-bristle toothbrush. Excessive pressure or improper brushing can cause localized injury to the delicate gingival tissues, leading to cleft formation.
2. Frenum Pull: The presence of a high frenum attachment near the gingival margin can exert tension on the interdental papilla or marginal gingiva, contributing to the development of a cleft.
3. Occlusal Trauma: Excessive or aberrant occlusal forces may also contribute by causing localized damage or inflammation to the gingival tissue.
4. Periodontal Disease: Although Stillman’s cleft can occur in the absence of periodontal disease, chronic inflammation or gingivitis may exacerbate tissue vulnerability.
5. Anatomical Predisposition: Thin or delicate gingival biotype may be more susceptible to cleft formation due to lesser resistance to mechanical trauma.

Clinical Features

Stillman’s cleft typically presents with the following clinical signs:

• A narrow, sharply demarcated, V-shaped or slit-like defect in the marginal gingiva, often located on the facial surface.
• The lesion may involve the interdental papilla or extend apically along the gingival margin.
• The affected area often shows denuded root surface or exposure of the cementoenamel junction (CEJ).
• Surrounding gingival tissue may appear inflamed or healthy depending on oral hygiene status.
• Patients may report sensitivity in the affected tooth due to root exposure.
• The site may be associated with marginal gingival redness or bleeding on probing if inflammation is present.
• Stillman’s cleft is more commonly observed in the anterior region, especially in the maxillary canine and premolar areas.

Diagnosis

The diagnosis of Stillman’s cleft is primarily clinical and involves careful intraoral examination:

• Visual Inspection: Identification of the characteristic narrow V-shaped notch on the marginal gingiva.
• Probing: Assessment of gingival sulcus depth around the cleft to rule out periodontal pockets.
• Patient History: Inquiry about oral hygiene habits, particularly brushing technique and frequency.
• Radiographic Examination: Generally, radiographs show no specific changes, but they are useful to exclude underlying bone loss or other pathology.
• Differential Diagnosis: It is important to distinguish Stillman’s cleft from other causes of gingival recession such as:
• Miller’s Class I-IV recession defects
• Gingival abrasion or erosion
• Frenum pull-induced recession
• Traumatic injury or chemical burns

Treatment

Stillman’s cleft, a localized gingival recession characterized by a narrow, V-shaped notch at the gingival margin, often accompanied by inflammation, requires careful managultraement to restore gingival health and prevent progres.

Treatment typically involves the following steps:

1. Initial Therapy:
– Thorough oral hygiene instruction to minimize trauma and plaque accumulation.
– Professional dental cleaning to reduce inflammation and promote healing.

2. Correction of Contributing Factors:
– Identification and modification of traumatic

(e.g., switching to a soft-bristled brush and gentle brushing motions).
– Addressing occlusal trauma, if present.

3. Surgical Treatment (if necessary):
– For persistent or advanced lesions, surgical intervention such as a connective tissue graft or a laterally positioned flap can be employed to cover the recession and restore gingival contour.
– The choice of technique depends on the size and depth of the cleft and patient-specific factors.

4. Maintenance:
– Regular dental check-ups to monitor gingival health.
– Continued reinforcement of proper oral hygiene practices.

Early diagnosis and management of Stillman’s cleft are essential to prevent further gingival recession and maintain periodontal health. Consulting with a periodontist can help determine the most appropriate treatment plan tailored to the individual case.