Outcome Of Root Coverage Procedures Research Articles

Influence of ternion of soft tissue attributes on gingival recession and root coverage outcome – A retrospective analysis

The independent influence of Keratinized Tissue Width (KTW) and Gingival Biotype (GB) on root coverage outcomes have been reported over the years. These parameters along with Recession Depth (RD) might act as a triad and assessing this ternion would be beneficial in determining prognosis and devising treatment plan for gingival recession. The aim of this retrospective analysis is to evaluate a possible association between KTW, GB and RD and their influence on Gingival Recession and root coverage outcome.45 isolated gingival recession defects were assessed for KTW (<2mm, >2mm), GB (thin vs thick) and RD (1-4mm). Primary outcome was to establish an association between the above-mentioned parameters. Secondary outcome was to find the percentage Root Coverage (%RC) obtained after coronally advanced flap procedure. To evaluate the relationship of KTW vs GB, GB vs RD and KTW vs RD, chi-square test was used. To analyse the intra-parametric correlation and the association between all three parameters, Pearson correlation test and ANOVA were carried out respectively.The Chi-square test results revealed a statistically significant association of p<0.03 for the relationship of KTW vs GB and GB vs RD and p<0.001 for KTW vs RD. Pearson correlation test showed a positive correlation between KTW and GB (.320), negative correlation between GB and RD (-.046), and KTW and RD (-.136). ANOVA showed a p-value of 0.041 inferring that any change in KTW and GB significantly influenced RD. Sites with <2mm KTW, thin GB and deeper RD, which can be referred to as negative ternion, exhibited 43.8% mean RC while sites with >2mm KTW, thick GB and shallow RD, which can be referred to as positive ternion had 94.7% mean RC. There is a definitive association between Keratinized Tissue Width, Gingival Biotype and Recession Depth. A ternion of these parameters greatly influences the outcome of root coverage procedures.

Treatment of Deep Isolated Gingival Recession Defects Affecting Mandibular Incisors: A Novel Interdisciplinary Orthodontic-Mucogingival Approach.

Tooth malposition negatively affects the outcome of root coverage procedures, limiting chances for complete root coverage (CRC). This case series introduces a combined orthodontic-mucogingival approach for the treatment of deep (> 4 mm) isolated gingival recession defects affecting mandibular incisors with a buccally displaced root. Twenty patients were treated with a novel orthodontic device (FZ Root Torque Controller) for selective correction of tooth malposition at the affected site, turning all isolated recessions into Miller Classes I and II. Subsequent surgical treatment of the gingival recession with a vertically-coronally advanced flap plus a connective tissue graft achieved 90% CRC at the 1-year follow-up, with a recession reduction of 5.6 ± 1.5 mm, a 1.24 ± 0.24 mm increase in gingival thickness, and improved esthetic outcomes.

Vertically Coronally Advanced Flap (V-CAF) to Increase Vestibule Depth in Mandibular Incisors.

Treatment of gingival recessions affecting mandibular incisors is scarcely documented. Despite a shallow vestibule depth being considered a poor anatomical condition, it has never been measured nor deemed a clinical parameter affecting the outcome of root coverage procedures. This study describes a vertically and coronally advanced flap (V-CAF) + connective tissue graft (CTG) technique to obtain root coverage and increased vestibule depth in the treatment of gingival recessions affecting mandibular incisors. Twenty patients with single gingival recessions were treated. The results showed that V-CAF+CTG is effective in increasing residual vestibule depth and in reducing recession depth. Immediately after surgery, a vestibule-depth increase of 5.9 ± 1.2 mm was reported, which was statistically significant compared to baseline, and it remained stable after 12 months (4.8 ± 1.1 mm). The mean percentage of root coverage was 98.3% ± 5.2% for all treated recessions, and complete root coverage (CRC) was achieved in 90% of cases (18 of 20). V-CAF+CTG could be considered a successful technique in terms of vestibule depth increase and CRC for the treatment of single gingival recessions in the mandibular incisors.

Therapeutic Prognosis System for Root Coverage Procedures.

Although several techniques and materials have been adopted to treat gingival recession, the therapeutic prognosis of various treatment modalities is not well established. This article proposes a multidimensional therapeutic prognosis system for the treatment of gingival recession based on the currently available literature. Gingival defect characteristics, patient behavioral habits, and surgical- and anatomical-related factors that may affect the outcome of root coverage procedures are reviewed. A therapeutic prognosis system is provided to enable clinicians to analyze these factors prior to the root coverage procedures. Three clinical cases are also discussed to demonstrate the assessment and validation of this therapeutic prognosis system.

Effect of root surface conditioning on gingival recession coverage with a connective tissue graft. A retrospective comparative study of three different agents

Different root modifiers have been proposed in the literature with an attempt to improve the healing process and the success rate of root coverage procedures. The aim of the present retrospective study was to evaluate the effect of three different types of root surface conditioning, namely, tetracycline (TTC), ethylene-di-amino-tetra-acetic acid (EDTA) and saline, on the outcome of root coverage procedures applying the same surgical technique. Twenty-nine patients with 60 Classes I, II, or III recession defects were treated using connective tissue with a partial-thickness double-pedicle graft. In 21 recession defects root surface was treated with TTC and, in other 21, with EDTA, while in the remaining, saline solution was applied. Statistical analysis consisted of descriptive statistics and Kruskal-Wallis, Mann-Whitney, and chi-square tests. Differences between pre- and postoperative values were statistically significant only within but not between groups. Mean root coverage was 73.25%, 69.19%, and 82.17% in the TTC, the EDTA, and the saline groups, respectively. The study revealed no statistically significant differences for all evaluated parameters between groups. Within the limits of this study, root conditioning, prior to root coverage procedures, does not significantly affect their outcome. Clinical outcome of root coverage procedures is not related to the type of root surface conditioning.

Analysis of root coverage esthetic score in patients treated for gingival recession: An interexaminer reliability.

Background:Awareness about pink esthetics among dentists in general needs to be assessed as root coverage procedures are the mainstay of treatment for gingival recession. Concordance among the dentists in figuring out the esthetic outcomes after root coverage procedures is inconsistent. Hence, this study aims to evaluate inter- and intra-examiner reliability of root coverage esthetic scores (RES) between periodontists and nonperiodontists.Materials and Methods:The study was conducted using twenty baseline and 6-month posttreatment photographs of Miller's Class I and Class II gingival recessions. The participants that constituted ten periodontists and ten nonperiodontists were assembled in the seminar hall to receive training on protocol and procedures for RES by the investigator. All the participants were shown twenty projections of side-by-side baseline and 6-month outcomes of root coverage procedures. Each projection was shown for 30 s during which the participants were made to use RES system to evaluate the surgical outcomes.Results:Periodontists showed the highest reliability in the scores of marginal tissue contour with an overall intraexaminer reliability to be perfect among periodontists. Intraexaminer reliability among nonperiodontists was fair, and gingival margin was the parameter with the highest reliability among them. Interexaminer reliability between periodontists and nonperiodontists showed slight reliability concerning gingival margin, and fair reliability was found for marginal tissue contour, soft-tissue texture, mucogingival junction, and gingival color.Conclusion:Satisfying the esthetic component of gingiva is the duty of every dentist in general and not only the periodontists. Significant variability was found in esthetic scores between the groups, which can probably be attributed to the lack of sufficient knowledge regarding pink esthetics among the nonperiodontists, which needs to be improved.

Assessment of patients' satisfaction following coverage of gingival recessions: Questionnaire-based case series

Background/Aim: One of the most important goals of periodontal plastic surgery constitutes the predictable root coverage. Despite the thorough documentation that several surgical approaches can be implemented for the successful treatment of gingival recession (GR), only limited papers reported data on the evaluation according to patient's opinion. Thus, the forthcoming study is aiming in the patient-based assessment of the outcome of root coverage procedures. Material and Methods: Sixteen subjects (eight male, eight female; mean age 43.75 years, range: 23-73 years) ,with twenty one GRs, constituted the sample of this study and the root coverage procedures were executed in the period from 2011 to 2019. A patient-based questionnaire was used to assess the level of subjects' concern on various aspects related to the GR, preand post-operatively. Patient's overall post-operative satisfaction was evaluated with a VAS. Results: After a period of at least 6 months of the surgical treatment, the majority of the subjects indicated that they were not concerned for all the examined criteria. The criteria with the highest improvement (reported as improvement by at least two levels of concern preand post-operatively) were the following: 1) fear to lose the involved teeth and 2) esthetics of the area of the recession defect. With regard to esthetics' criteria, the majority of the patients indicated post-operatively the examined criteria as not important. The esthetics' criteria yielding the highest improvement were: 1) position of the teeth and 2) the fact that the teeth showed longer. Mean patient's overall post-operative satisfaction was 82,3 (range: 0-100). Conclusions: The majority of the subjects were satisfied from the implemented root coverage procedures. Few studies on the international literature have evaluated patient satisfaction following therapy. Comprehensive, multi-center studies, comprised of a large sample and a using a standardized approach are needed in future research.

The root coverage esthetic score: Intra-examiner reliability among dental students and dental faculty.

The root coverage esthetic score (RES) was published in 2009 as an esthetic scoring system to measure visible final outcomes of root coverage procedures performed on Miller I and II recession defects. The aim of this study was to evaluate the intra-examiner, intra-group, and inter-examiner reliability of the RES when used among periodontal faculty, post-graduate students in periodontology, and pre-doctoral DMD students when using the RES at Tufts University School of Dental Medicine (TUSDM). Thirty-three participants (12 second-year DMD students, 11 periodontal residents, and 10 faculty members) were assembled to evaluate 25 baseline and 6-month post-treatment outcomes of mucogingival surgeries using the RES. Each projection was shown for 30 seconds during which the participants were asked to use the RES scoring system to evaluate the surgical outcomes. The results were then recorded on a standardized worksheet grid. To test intra-examiner reliability, seven of the 25 projections were shown twice. Intra-examiner reliability and inter-examiner reliability were assessed using intraclass correlation coefficient using a two-way mixed effect model, and stratified by education level. Post-graduate (PG) residents had the highest tendency to agree with each other with an interclass correlation (ICC) of 0.53 (95% confidence interval [CI] 0.36 to 0.74). DMD students had an ICC: 0.51 (95% CI: 0.33 to 0.75), and PG faculty members produced an ICC: 0.41 (95% CI: 0.24 to 0.64). There was no statistically significant difference in ICC among the three groups of participants (Kruskal-Wallis test, P=0.2440). When the data for each RES element were then combined, the mean ICC for the total inter-rater agreement for RES was 0.48 (95% CI: 0.32 to 0.71). This corresponds to an overall moderate agreement among all participants using the RES to evaluate the 25 surgical outcomes. The intra-examiner reliability within each of the three groups was quite high. The highest mean ICC was produced by PG faculty (0.908). The mean ICCs for PG residents was 0.867, and the mean ICC for DMD students was 0.855. The Kruskal-Wallis test (P=0.46) failed to find any statistical difference in intra-examiner reliability among the three groups of participants. The RES is a "moderately" reliable scoring system for mucogingival treatments in a dental school setting and can be used even by operators with different levels of periodontal experience. This scoring system can be repeated by the same examiner to obtain reliable results.

Clinical Considerations on the Root Coverage of Gingival Recessions in Thin or Thick Biotype.

Gingival biotype is a clinical term used to describe the thickness of the gingiva. It has been classified as being thick or thin and may be related to the clinical outcome of root coverage procedures. This study evaluated the impact of gingival biotype on the clinical outcome of root coverage procedures following subepithelial connective tissue graft plus coronally positioned flap. A total of 19 patients, 10 with thin and 9 with thick gingival biotype, were treated for localized Miller Class I or II gingival recessions. After 6 months, 14 patients achieved complete root coverage, 7 from each group. The overall mean pooled root coverage rate was 90.93%. The thin biotype cases yielded a reduced mean root coverage of 88.51% compared with 93.63% for patients who had the thick biotype classification. Although the thin gingival biotype may impair the clinical outcome of root coverage procedures, this limitation does not appear to have a strong influence on the success of the root coverage therapy when subepithelial connective tissue graft was associated with the coronal positioning of the flap.

Analysis of the Esthetic Outcome after Root Coverage Procedures Using a Comprehensive Approach

There is a reported gap between the relative satisfaction of the clinician and patient after a root coverage procedure. In addition, there may also be a disparity between objective esthetic evaluation tools and subjective satisfaction. This study included 58 sites in 31 patients who had undergone root coverage procedures. The percentage of root coverage and the root coverage esthetic score system were used as objective measurements. A questionnaire with a five-point ordinal scale was used for subjective evaluation. Initial recession depth and width, Miller classification, tissue biotype, treatment procedures, and follow-up periods were considered as associated factors. After a period of at least 6 months from the procedure, the patient-perceived outcome showed a better match with the root coverage esthetic scoring system than the percentage of root coverage alone. A lower value for objective outcome was obtained for a deeper gingival recession and higher Miller class, but the subjective outcome displayed a steady trend. All four esthetic results were at their lowest after an epithelialized free soft tissue graft. An esthetic outcome according to patient satisfaction was not always consistent with that determined by professional scoring. In addition, partial root coverage may be viewed as a positive outcome by patients and clinicians in cases of deep gingival recession and high Miller class. This study evaluates the esthetic outcome of root coverage procedures using an objective method, including the percentage of root coverage, root coverage esthetic scoring system, and subjective assessment by patient and clinician-based questionnaires. The results will be helpful for the understanding of the differences that exist in esthetic satisfaction.

Root Coverage Esthetic Score After Treatment of Gingival Recession: An Interrater Agreement Multicenter Study

The root coverage esthetic score (RES) system was proposed for evaluating esthetic outcomes of root coverage procedures. The aim of this multicenter study is to assess the interrater agreement of the RES among expert periodontists. Eleven periodontists were selected in different clinical centers. Each operator had ≥15 years of experience in mucogingival surgery. Each periodontist was trained to use RES before the beginning of the study. Subsequently, baseline and post-treatment (6 months) photographs of 41 Class I and II gingival recessions in 41 patients were separately given to each operator who evaluated the outcomes according to the RES method. A two-way random interclass correlation coefficient and 95% confidence interval (CI) were used to assess the global interrater agreement for RESs. The total interrater agreement for RESs was 0.92 (95% CI: 0.88 to 0.95), which indicated that an almost perfect agreement was achieved. Tested individually by a group of periodontists, the RES seems to be a reliable method for assessing the esthetic outcomes of root coverage procedures.

Influence of crown shape on root coverage therapy

Objectives:The aim of this study was to evaluate the influence of the crown shape on the outcomes of root coverage procedures.Material and methods:Eighty patients with Miller class I gingival recessions in maxillary canines or premolars were selected. The recession areas were treated using the subepithelial connective tissue grafting. The following clinical parameters were analyzed: crown length (CL) and width (CW), recession height and width, probing depth, clinical attachment level, width and thickness of the keratinized tissue and percentage of root coverage achieved. These measurements were recorded at baseline and 6 months after the surgical procedure. The CW/CL ratio was calculated for each tooth and the median obtained (0.83). Patients were then ranked into two groups, according to the shape of the tooth with gingival recession: Group A – square crown shape (CW/CL values above 0.83) and Group B – long and narrow crown shape (CW/CL values below 0.83).Results:No statistically significant differences (p>0.05) were found between groups in any of the clinical parameters at baseline. After 6 months, both groups presented improved clinical outcomes for all parameters analyzed compared to baseline (p>0.05). The mean percentages and standard deviations of root coverage achieved in Group A and Group B was 91.37 (16.75) and 85.49 (23.55), respectively (p>0.05).Conclusions:Crown shape did not influence the root coverage obtained with the subepithelial connective tissue graft technique.

Coronally Advanced Flap: The Post‐Surgical Position of the Gingival Margin Is an Important Factor for Achieving Complete Root Coverage

An assessment of the factors affecting the clinical outcome of root coverage procedures may be useful in clinical decision making. The aim of this study is to investigate whether the post-surgical location of gingival margin relative to the cemento-enamel junction (CEJ) can influence the recession reduction (RecRed) and complete root coverage (CRC) following coronally advanced flap procedure (CAF). Sixty patients, aged between 22 and 57 years, 15 males and 45 females, each showing maxillary buccal recessions (> or =2 mm) identified as Miller's Class I were consecutively enrolled. All the defects were treated by CAF procedure from 2000 to 2003 by a single operator with more than 20 years of clinical experience. Age, gender, smoking habits, and type of tooth of each patient were recorded. In addition, the following clinical data were measured or computed: recession depth, width of keratinized tissue, probing depth, distance between incisal margin (IM) and CEJ, dental hypersensitivity, clinical attachment level, distance between IM and gingival margin (IMGM), distance between IM and mucogingival junction (IMMG), and the location of gingival margin relative to the CEJ following CAF procedure (GM(1)). A multiple linear regression, and a logistic linear regression analyses were performed. The recession depth at baseline (Rec(T0)) and the location of the gingival margin after suturing (GM(1)) are positively correlated to recession reduction. Complete root coverage appeared to be influenced by GM(1): the more coronal the level of the gingival margin after suturing (GM(1)), the greater the probability of CRC. The location of the gingival margin relative to the cemento-enamel junction following CAF procedure seems to affect CRC.

A Critical Evaluation of Methods for Root Coverage

Gingival recession is the exposure of root surfaces due to apical migration of the gingival tissue margins. Although it seldom results in tooth loss, marginal tissue recession is associated with thermal and tactile sensitivity, esthetic complaints, and a tendency toward root caries. This article reviews the current surgical procedures for the coverage of exposed root surfaces, including their advantages and disadvantages. Today, the outcome of root coverage procedures is predictable, aesthetically acceptable, and, together with the use of guided tissue regeneration, at the forefront of regenerative procedures.