PRACTICAL APPLICATIONS
A New Index Proposed for Determination of Outcome
of Recession Coverage Procedures
Nymphea Pandit,* Amit K. Gaba,* Rajvir Malik,* and I. K. Pandit*
Focused Clinical Question: How can the clini-
cal outcome of recession coverage procedures be deter-
mined in cases of malaligned and rotated teeth?
Summary: The primary impetus that led to the de-
velopment of the various indices of gingival recession
coverage procedures was to correlate the prognosis to
the anatomic features.Two important anatomic features,
i.e. rotation and proclination of teeth, affect the topogra-
phy of the labial bony plate as well as the biotype of the
soft tissue overlying the root surface and consequently
the treatment outcome. The purpose of this article is to
propose an index for predetermination of the outcome
of gingival recession coverage procedures, depending
on the extent of rotation or proclination of the teeth to
be treated. The study population consisted of 12 patients
(22 sites) with Miller Class I and Class II recession of man-
dibular/maxillary teeth. These recession defects were
treated with subepithelial connective tissue graft proce-
dures. Clinical parameters assessed were percentage
of recession coverage achieved at 6 months post-surgi-
cally. A malalignment index (MI) was devised and inter-
preted for its prognostic value with respect to the
treatment executed for the recession coverage proce-
dure. The Pearson correlation between percentages
of recession coverage achieved and the MI scores
assessed was 0.015, which is statistically significant.
Conclusion: This clinical study concludes that
the proposed MI will be of high prognostic value, in
predetermination of the success of the root recession
coverage procedures in proclined and rotated teeth.
Clin Adv Periodontics 2012;2:49-55.
Key Words: Connective tissue; gingival recession;
malocclusion; prognosis.
Background
Repairing mucogingival defects to maintain esthetic and
functional tissue is always a challenge. The treatment of
buccal gingival recession for esthetics or root sensitivity is
a frequent demand in patients with high standards of oral
hygiene.1 Clinically, healthy gingival margin around a
tooth is represented by a scalloped line that follows the
* Department of Periodontology and Implantology, D.A.V. Centenary Dental
College and Hospital, Yamuna Nagar, Haryana, India.
Submitted February 10, 2011; accepted for publication April 13, 2011
doi: 10.1902/cap.2011.110012
outline of the cemento-enamel junction (CEJ). Location of
this gingival margin is further dependent on the underlying
topography of bone, which itself is dependent on the
position (proclination or retroclination) of the tooth.2
Consequently, the outcome of various recession coverage
procedures depends primarily on the position of the tooth
and the topography of underlying bone along with several
other factors.
Probable course, duration, and outcome (prognosis) of
a disease are based on general knowledge of the pathogen-
esis of the disease and the presence of risk factors for the
disease. Clinicians use a wide variety of variables to estab-
lish a prognosis, including anatomic factors, diagnosis of
periodontal conditions, age, plaque level, smoking status,3
severity of attachment loss, control of etiologic factors, oc-
clusal loading, and genetic and systemic makeup. However,
anatomic factors that may predispose the periodontium to
recession and, therefore, affect the prognosis include bio-
type of overlying gingiva,4 proclination or rotation of the
teeth in the arch,5 presence of fenestration, or dehiscence
on underlying bone.6
Decision Process
Effects of Soft-Tissue Biotype on Recession
Coverage
A case series4 indicated that flap thickness is associated
with frequency of complete root coverage in coronally po-
sitioned flap procedures. The thinner the soft tissue, the
more difficult the procedure is, and the higher the risk of
postoperative necrosis. Soft-tissue thickness ‡0.8 mm is
needed for complete coverage with a coronally positioned
flap, whereas tissue <0.8 mm in thickness more often re-
sults in incomplete coverage. Cases of root recession
treated with guided tissue regeneration are more likely
to get complete coverage when thick tissue is present.7
The existence of two types of gingival biotypes (thin-
scalloped and thick-flat) has been confirmed.8
Effects of Proclination of Tooth on Osseous
Topography and Soft-Tissue Biotype
In teeth with labial version, the margins of labial bone are
located farther apically than on a tooth in proper align-
ment. The bone margins are thinned to knife-edged and
present an accentuated arc in the direction of the apex
(Fig. 1)
Labial protrusions of root combined with thin bony
plate are predisposing factors for fenestration and dehis-
cence, which can also complicate the outcome of recession
Clinical Advances in Periodontics, Vol. 2, No. 1, February 2012 49
P R A C T I C A L A P P L I C A T I O N S
FIGURE 1 Schematic diagram showing a normally inclined tooth with
adequate thickness of gingiva and alveolar bone (1a) and a proclined tooth
with gingival and alveolar thinning (1b).
coverage therapy.2 Adequate vascular supply is essential to
achieve complete root coverage. This may be obtained
from the bone, periosteum, and periodontal ligament un-
derlying the graft and from flap tissue overlying the graft.
So, if bone is present apically and is thin, then a lesser
amount of blood supply will be available to nourish the
overlying flap as well as graft.9
Effects of Tooth Rotation on Soft- and Hard-
Tissue Topography
The topographic relationship in rotated teeth, between the
CEJ and the interdental papilla mesial and distal to a tooth
with recession, changes at one tooth side (mesial or distal
according to sense of rotation), and the CEJ is closer to
the tip of the papilla, whereas at the other side it is farther.
The situation in which the CEJ is closer to the tip of the an-
atomic papilla causes a loss of papilla height clinically sim-
ilar to that caused by trauma. The only difference between
these situations is that one or both of the interdental papilla
can be involved in the case of traumatic loss, whereas in the
case of tooth rotation, the height of only one papilla is re-
duced. Root coverage surgical techniques will leave a por-
tion of root surface uncovered at the toothside where
there is reduction of papilla height; this is often erroneously
considered failure of root coverage procedure.1
Comparison of Previous Classifications and
Indices
Possibly the first classification of recession by Sullivan and At-
kins in 196810 had a morphologic basis, but it had no predic-
tive value regarding treatment outcome.
A landmark classification of recession was given by
Miller in 198511 who enhanced the predictability of root
50 Clinical Advances in Periodontics, Vol. 2, No. 1, February 2012
coverage by presurgical examination and its correlation
with the recession, although this classification did not in-
clude the position of the tooth (proclination/rotation),
thickness of overlying gingiva, and alveolar ridge.
In 1997, Smith12 proposed a recession index to describe
the extent of recession on lingual and facial aspects with its
horizontal and vertical components, but again there was no
prognostic value.
To determine the success rate of recession coverage pro-
cedures in malaligned teeth (proclined or rotated) and to
compare it to the success rate in properly aligned teeth,
we devised an index, named the malalignment index (MI).
MI
We hereby propose a comprehensive and objective, self-de-
vised index (Table 1) in which the phenomenon of proclina-
tion and rotation (mesial/distal rotation) of the mandibular/
maxillary anterior teeth, which are thought to halt the
success of root coverage procedures, are considered. Impres-
sions of mandibular or maxillary arches were taken with
elastic irreversible impression material when treatment
was required. A dental stone cast was fabricated, and all
the measurements were made on this cast. A stainless steel
wire (26 gauge) was adapted, contacting the mesial pit of
the first permanent molar of one side, passing over the lin-
gual/palatal cusps of premolars, contacting the cingulum
area of anterior teeth, and continuing on the opposite side
on the same pattern up to the mesial pit of the opposite first
permanent molar. Once adapted, the wire was placed on the
arch wire template† (Fig. 2) for standardization of the adap-
ted wire. The arch wire template is a transparent symmetric
grid made of plastic. On this template, there are three pat-
terns of arches (both mandibular and maxillary) printed
(i.e., square, taper, and oval) over which the preadapted wire
can be superimposed (from canine to canine region) to know
the pattern of the arch as well as determine the standardiza-
tion of the adaptation. Proclination (Figs. 3 and 4) and ro-
tation (Figs. 5 and 6) of the teeth can be measured with
a caliper‡ according to scoring criteria (Table 1).
Note the following: 1) if the first molar is absent, then the
distal pit of the second premolar can be used as a reference
point for adapting the wire; 2) if both the mesial and distal
line angles of the tooth under consideration are away from
the wire to different extents, then the mean of both dis-
tances is taken and scored accordingly under proclination.
Limitations
The following are limitations: 1) Only the location of
a tooth in the arch was considered (neither the interprox-
imal bone level nor the soft tissues were considered). These
are primary predictors11 for success of complete root cov-
erage. The reason was to avoid the exposure of the patient
to x-rays. 2) The ideal method to determine the pattern of
teeth in an arch is cephalometric analysis, but this diagnos-
tic tool was not used so as to avoid the exposure to x-rays.
†
Sym Grid, Desire KDP, Mumbai, India.
‡
Vernier, Beaverton, OR.
Malalignment Index
 P R A C T I C A L A P P L I C A T I O N S

TABLE 1 Scoring Criteria of MI

Score Criteria

0 No malalignment (no proclination, no mesial,

and no distal rotation); i.e., both mesial and
distal halves of the tooth are touching the
stainless steel wire.

1 Mild mesial rotation or distal rotation; i.e.,

mesial or distal half of the tooth is £1 mm
away from the stainless steel wire.

2 Moderate mesial rotation or distal rotation;

i.e., mesial or distal half of the tooth is 1 to
2 mm away from the stainless steel wire. FIGURE 3 Both line angles are equally away from the stainless steel wire,
indicating proclination.
3 Severe mesial rotation or distal rotation; i.e.,
mesial or distal half of the tooth is >2 mm
away from the stainless steel wire.

4 Mild proclination; i.e., both mesial and distal

halves of the tooth are £1 mm away from the
stainless steel wire.

5 Moderate proclination; i.e., both mesial and

distal halves of the tooth are 1 to 2 mm away
from the stainless steel wire.

6 Severe proclination; i.e., both mesial and

distal halves of the tooth are ‡2 mm away
from the stainless steel wire.

FIGURE 4 Schematic diagram showing the relationship of the adapted

wire to proclined tooth #24.
FIGURE 2 Arch wire template.

Dental College and Hospital (Yamuna Nagar, Haryana, In-

3) If ‡1 teeth are out of alignment in the arch, then it is dif-
ficult to adapt the wire.
Clinical Scenario
Twelve systemically healthy patients (seven males and five
females; aged 21 to 51 years) with 22 sites of Class I and II11
gingival recessions (mandibular/maxillary teeth), were in-
cluded in this study from August 2009 to December 2010.
These participants were selected from the patients attend-
ing the outpatient department of the Department of Peri-
odontology and Implantology of the D.A.V. Centenary
dia). Recession defects associated with smokers, systemic
disease, caries, and restorations were excluded. The study
protocol involved a screening consultation followed by ini-
tial therapy to establish optimal plaque control and gingi-
val health, surgical therapy, post-surgical consultations,
and post-surgical evaluation after 6 months.
Clinical Management
After local anesthesia was administered, the root surface
was carefully planed to remove plaque and calculus and
to flatten the root in areas of root prominence. Horizontal

Pandit, Gaba, Malik, Pandit Clinical Advances in Periodontics, Vol. 2, No. 1, February 2012 51
P R A C T I C A L A P P L I C A T I O N S
FIGURE 5 The mesial line angle of teeth #24 and #25 touch the stainless
steel wire, whereas the distal line angles are away from stainless steel wire
because of rotation.
FIGURE 6 Schematic diagram showing the relationship of the adapted
wire to rotated teeth #24 and #25.
right angle incisions were made into the adjacent interden-
tal papillae mesially and distally to the defect, at or slightly
coronal to the level of the CEJ of the tooth presenting the
recession. A sulcular incision was made connecting the hor-
izontal incisions. A partial thickness dissection was then
performed extending apically beyond the mucogingival
junction and mesiodistally beyond the osseous margins
of the bony dehiscence. Donor connective tissue with 1-
to 2-mm epithelial collar was harvested from the molar–
premolar area of the palate using two parallel horizontal
incisions located ‡2 mm apically to the gingival margin
of maxillary teeth. The graft dimensions were determined
52 Clinical Advances in Periodontics, Vol. 2, No. 1, February 2012
to allow the coverage of the surgically exposed root surface
and the adjacent periosteum of the recipient site. The donor
connective tissue was secured in position with its coronal
margins in correspondence to the CEJ with interrupted bi-
oresorbable sutures.x The overlying partial thickness flap
was sutured over the graft using bioresorbable interrupted
suturesk into the interproximal papillae with no attempt to
completely cover the donor tissue.
Postoperative Care
Patients were subjected to a post-surgical protocol consist-
ing of analgesics and 0.12% chlorhexidine, three times
daily for 3 weeks after surgery. Sutures were removed 10
to 15 days post-surgery. Patients were asked to avoid me-
chanical plaque control until healing had progressed suffi-
ciently to allow resuming normal oral hygiene measures.
Outcomes
Clinical measurements of the distance from the gingival
margin to the CEJ were recorded to the nearest millimeter
with a thin manual periodontal probe{ immediately before
the surgical procedure and 6 months after the surgical
procedure. MI scores were calculated as described above.
The outcome of the variables was reported as the per-
centage of recession coverage achieved and MI scores.
The descriptive statistics were based on calculation for
the mean, standard deviation, number of each variable,
and Pearson correlation and significance. Recession defects
were treated with subepithelial connective tissue graft pro-
cedure. Clinical parameters assessed include the percentage
of recession coverage achieved and MI scores. The mean of
the percentage of root coverage achieved was 70.07 –
21.36, and the mean of the MI scores was 1.60 – 1.92.
The statistically significant (P <0.015) Pearson correlation
was found between the percentage of recession coverage
achieved and the MI scores (Table 2); from this study,
we can conclude that the percentage of recession coverage
achieved is significantly correlated to the MI scores.
Discussion
Periodontitis and toothbrushing trauma are considered the
most significant factors causing gingival recession, partic-
ularly when associated with predisposing factors such as
thin gingival biotype, prominent root surface, buccally po-
sitioned teeth, and bony dehiscences.13
Root recession coverage procedures are not very predict-
able. It is important to differentiate between success and pre-
dictability with regard to root coverage procedures. Success
of root coverage procedures is related to the average percent-
age of root coverage achieved (Table 3), whereas predictabil-
ity (Table 4) describes the percentage of the treated teeth in
which complete root coverage is achieved.14
In our study, we applied the MI to a small population and
found there was a correlation between malocclusion and
x
VICRYL 4-0, Ethicon, Johnson & Johnson, Cornelia, GA.
k
VICRYL 4-0, Ethicon, Johnson & Johnson.
{
UNC PCP-15 probe, Hu-Friedy, Chicago, IL.
Malalignment Index
 P R A C T I C A L A P P L I C A T I O N S

TABLE 2 Pearson Correlation Between Recession Coverage

and MI Score (n¼22)

Pearson Correlation Significance (Two-Tailed) MI

0.510* 0.015 1
* Correlation is significant at the 0.05 level (two-tailed).

TABLE 3 Success of Connective Tissue Grafts for Root Coverage

Treatment Modality No. of Studies Mean % of Root Coverage Achieved Range of Root Coverage Achieved

Connective tissue graft 33 86% 53% to 98%

14
Data from Wennström et al.

TABLE 4 Predictability of Connective Tissue Grafts for Root Coverage

Treatment Modality No. of Studies Mean % of Root Coverage Achieved Range of Root Coverage Achieved

Connective tissue graft 26 61% 0% to 93%

14
Data from Wennström et al.

recession coverage obtained after connective tissue graft
procedures. At six sites, we obtained 100% root coverage,
and the MI score was 0 (Figs. 7a and 7b). At two sites, the
mean recession coverage obtained was 53.55%, and the
MI scores were 6, i.e., severe proclination (Figs. 8a and
8b). In one patient, two adjacent sites with MI scores
0 and 2 (rotation) were treated, and the recession coverage
obtained was 50% and 42.8%, respectively (Figs. 9a and
9b). This suggests that if a malaligned tooth is present with
an adjacent properly aligned tooth, it can also affect the
overall recession coverage achieved.
In most cases of recession coverage procedures, root con-
vexity is reduced by either mechanical or rotary grinding of
root surface. In any event, if root coverage after treatment is
incomplete, grinding the abrasion or root planing the CEJ
can lead to increased hypersensitivity. This can be avoided
if we can predetermine the approximate extent of root cov-
erage to be obtained after mucogingival procedures.
During the course of this study, it was observed that one
patient with root recession of 5 mm in teeth #24 and #25
with MI scores of 3 was treated with regenerative tissue.#
No coverage at all was achieved in this case. Subsequently,
the tooth was aligned orthodontically within the arch, so
that an MI score of 0 was achieved. After 2 years, the tooth
was treated with connective tissue graft, obtaining 100%
root coverage. This particular case further indicates the
usefulness of MI and its correlation with the predictability
of the outcome of the recession coverage procedures.
Conclusion
The present clinical study concludes that the proposed MI
will be of high prognostic value, in predetermination of the
success of the root recession coverage procedures in pro-
clined and rotated teeth. n
Acknowledgments
No external funding apart from the support of the authors’
institution was provided for this study. The authors report
no conflicts of interest related to this study.
CORRESPONDENCE:
Dr. Nymphea Pandit, Department of Periodontology and Implantology,
DAV Centenary Dental College and Hospital, Model Town, Yamuna Nagar,
Haryana, India, 135001. E-mail: drnymphea@yahoo.com.

#
AlloDerm, LifeCell, Branchburg, NJ.

Pandit, Gaba, Malik, Pandit Clinical Advances in Periodontics, Vol. 2, No. 1, February 2012 53
P R A C T I C A L A P P L I C A T I O N S

FIGURE 7a Clinical preoperative photo showing well aligned tooth (according to MI). 7b Clinical postoperative photo showing well aligned tooth (according to
MI) with 100% recession coverage achieved (arrow).

FIGURE 8a Clinical preoperative photo showing severely proclined tooth (according to MI) (arrow). 8b Clinical postoperative photo showing severely proclined
tooth (according to MI) and partially achieved recession coverage (arrows).

FIGURE 9a Clinical preoperative photo showing rotated tooth (according to MI) adjacent to a well-aligned tooth (according to MI) (arrows). 9b Clinical
postoperative photo showing rotated tooth (according to MI) adjacent to a well-aligned tooth (according to MI), with partially achieved recession coverage in
both (arrows).

54 Clinical Advances in Periodontics, Vol. 2, No. 1, February 2012 Malalignment Index


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