Periodontal Root Coverage: An Evidence-Based Guide to Prognosis and Treatment

By Khadija Amine, Wafa El Kholti and Jamila Kissa

This book is an evidence-based guide to periodontal root coverage that provides up-to-date information on the etiology of gingival recession defects, prognostic factors relating to the defect, patient, or operator, and surgical techniques. Attention is drawn to critical elements in the execution of surgical procedures that can impact on outcomes. In order to ensure that the guidance reflects the highest level of evidence, the authors have undertaken an exhaustive literature search of the four main electronic databases (MEDLINE/PubMed, Cochrane Library, ScienceDirect, and EBSCOhost) for studies on root coverage, including randomized clinical trials, systematic reviews, meta-analyses, and network meta-analyses. The aim is to supply readers with a truly reliable source of knowledge that will help them to navigate this complex field, in which numerous surgical procedures have been described, with great variability in clinical and statistical outcomes. The book will be of value to all who wish to improve their understanding of gingival recession defects and the techniques to achieve root coverage that offer the best long-term results.

• Language: English
• Publisher: Springer
• Release date: Oct 9, 2019
• ISBN: 9783030200916

Book preview

Part I

Background

Gingival recession is a mucogingival defect referred to the buccal exposure of the root surface of the tooth as a consequence of an apical migration of the gingival margin up to the cementoenamel junction. This pathological process involves both gingiva and the underlying bone. Thus, bone dehiscence should be present for gingival recession to occur. Bone dehiscence or fenestration could be anatomical, pathological, traumatic, or iatrogenic. From an epidemiological point of view, gingival recessions are more prevalent and more advanced in aged patients and they are significantly more frequent in males than females. The current evidence suggests that the etiology of gingival recession could be multifactorial and numerous factors should be taken into account in diagnosis phase.

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Gingival recession is a mucogingival defect referred to the buccal exposure of the root surface of the tooth as a consequence of an apical migration of the gingival margin up to the cemento enamel junction

© Springer Nature Switzerland AG 2019

K. Amine et al.Periodontal Root Coverage https://doi.org/10.1007/978-3-030-20091-6_1

1. Gingival Recessions: Definition and Classification

Khadija Amine¹ , Wafa El Kholti¹ and Jamila Kissa¹

(1)

Periodontics Department, University of Hassan II, Casablanca, Morocco

1.1 Definition

In the normal situation, the gingival margin draws a scalloped line located 1 or 2 mm coronally to the cementoenamel junction (CEJ) [1]. Gingival recession is a mucogingival defect referred to the buccal exposure of the root surface of the tooth as a consequence of an apical migration of the gingival margin up to the CEJ [2, 3]. This pathological process involves both gingiva and the underlying bone. Thus, bone dehiscence should be present for gingival recession to occur (intrinsic mechanism) [4]. In some situations, the gingival relapse could slightly expose underling bone. This situation could explain the extrinsic pathological mechanism of gingival recession [5].

Regarding the epidemiology of gingival recessions, these mucogingival defects are more prevalent and more advanced in aged patients, and they are significantly more frequent in males than females [6–8]. Albandar and Kingman [6] estimated that 23.8 million of adults in USA have at least one tooth surface with a gingival recession (≥3 mm). Gingival recessions were much more prevalent and more advanced at the buccal surfaces than on other aspects of the tooth [6]. This study is in agreement with a Brazilian one conducted by Susin et al. [8]. The authors reported that 51.6% (GR ≥3 mm) and 22% (GR ≥5 mm) of the subjects have at least one gingival recession. The authors reported that the prevalence of gingival recession expands with age (a nonlinear relationship was noted), and it is more frequent in males than females.

1.2 Classifications

1.2.1 Classification of Sullivan and Atkins [9]

In this classical classification, four classes of soft tissue defects were described according to the gingival recession dimensions (depth and width). Better root coverage results were reported for narrow and shallow gingival recessions [9]. From a prognostic point of view, this classification does not take into account some prognostic factors especially the interdental attachment loss. Thus, it is not suitable for a clinical practice (Fig. 1.1).

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Fig. 1.1

Sullivan and Atkins Classification of gingival recessions [9]. (a) Deep-narrow, (b) deep-wide, (c) shallow-narrow, and (d) shallow-wide

1.2.2 Classification of Miller [10]

Miller [10] described gingival recessions according to the soft and hard tissues.

Class I: The gingival recession doesn’t extend to the mucogingival junction (MGJ). There is no loss of interproximal hard or soft tissues.

Class II: The gingival recession extends to the MGJ. There is no loss of interproximal hard or soft tissues. Moreover, this classification could be divided into two sub-groups:

Class IIa: A very narrow band of keratinized gingiva (1 mm or less) stills remaining apically to the gingival defect.

Class IIb: No keratinized gingiva band is distinguished apically to the gingival recession.

Class III: The gingival recession extends to or further on the MGJ, with some interproximal attachment losses. The gingival margin is located apically to the interdental bone.

Class IV: The gingival recession extends to or further on the MGJ, with an advanced interproximal attachment loss. The gingival margin is located coronally to the interdental bone (Figs. 1.2, 1.3, and 1.4).

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Fig. 1.2

Miller Classification of gingival recessions [10]. (a) Cl I, (b) Cl II, (c) Cl III, and (d) Cl IV

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Fig. 1.3

Miller Class IIa gingival recession

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Fig. 1.4

Miller Class IIb gingival recession

Based on Miller’s classification [10], complete root coverage can be predicted in Class I and II. In Class III, only partial root coverage could be predicted according to the severity of interdental attachment loss. However, root coverage is not possible in Class IV.

In last decades, most authors and clinical studies used the classification of Miller [10] in their protocols. However, some confusion about this classification has recently been highlighted such as the difficult differentiation between class I and II, the uncertain techniques to identify the amount of interdental attachment loss to differentiate between class III and IV, and the negative impact of tooth malposition on this classification [1, 11].

1.2.3 Classification of Cairo [11]

Cairo et al. [11] have introduced a new classification of gingival recession defects based on the interdental clinical attachment loss as the main parameter to define gingival recession type:

Gingival recession type 1 (GRT1): GR with no interdental attachment loss. The interdental CEJ is not detectable clinically (Miller Class I and II GR).

Gingival recession type 2 (GRT2): GR with an interdental attachment loss. The amount of the interdental attachment loss is less than or equal to the oral attachment loss (Miller Class III GR).

Gingival recession type 3 (GRT3): GR with an interdental attachment loss. The amount of the interdental attachment loss is higher than the oral attachment loss (Miller Class IV GR).

The authors concluded that the clinical and radiological assessments of interdental attachment loss might be useful as a guide for the diagnosis of gingival recessions and the prognosis of root coverage (Fig. 1.5).

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Fig. 1.5

Cairo classification of gingival recessions [11]. (a) GRT1, (b) GRT2, and (c) GRT3

References

1.

Zucchelli G, Mounssif I. Periodontal plastic surgery. J Periodontol. 2015;68:333–68.Crossref

2.

Amine K, El Kholti W, Mortaziq A, Kissa J. Root coverage: prognostic factors and surgical techniques. Rev Stomatol Chir Maxillofac Chir Orale. 2016;117:403–10.

3.

Chambrone L. Evidence based periodontal and peri-implant plastic surgery. A clinical roadmap from function to aesthetics. Cham: Springer; 2015.Crossref

4.

Zuhr O, Hurzeler M. Plastic-esthetic periodontal and implant surgery. A microsurgical approach. London: Quintessence;