Franc~sco Cairo,Roberto Rotundo, Preston D. Miller Jr.

, and Giovan Paolo Pini Prato

Journal Of Periodontology Vol.80 No.4 April-2009

Presented by: Guided by:

Dr. Motilal Jangid

Dr.S.S.Doiphode Dr.P.S.Rakhewar

The treatment of gingival recession defects is indicated for esthetic reasons, to reduce root sensitivity, to remove muscle pull, and to create or augment keratinized tissue. Ann Periodontal 1996;1.

Clinical outcomes following root-coverage procedures are generally reported in terms of the percentage of root coverage and sometimes in terms of complete root coverage (CRC).
A study by Rotundo R, Nieri M,etc. on evaluating the esthetic perception of simulated root-coverage procedures on photographs showed that CRC is considered the most important outcome by patients, dentists, and periodontists.

A recent systematic review by Cairo F, Pagliaro U, Nieri M showed that a connective tissue graft in conjunction with a coronally advanced flap was associated with the highest probability of CRC. Journal Clin Periodontal 2008,35 The evaluation of the level of the gingival margin (GM) following surgery may be restrictive and not adequate to assess the overall esthetic results. In fact, esthetic failure may occur in cases of partial root coverage, as well as with poor color match, malalignment of the mucogingival junction (MGJ), and keloid-like texture.

Patient esthetic demands have become more stringent; thus, root-coverage procedures should provide soft tissue anatomy comparable to and indistinguishable from adjacent tissue.

To achieve this goal, mucogingival techniques used to treat gingival recession defects have improved.

Free gingival grafts, although effective in gaining root coverage, are compromised esthetically.
Bilaminar approaches and techniques for the treatment of multiple recession defects have been developed, leading to improved esthetic results. J Clin Periodontal 2003;30:862-870.

In addition, the use of magnification, microsurgical instruments, and smaller sutures has led to more delicate soft tissue management, thus enhancing the final esthetic outcome.

Esthetic assessment is subjective and might be influenced by cultural background.

However, an objective esthetic evaluation should be useful when the outcomes of cosmetic surgery are assessed. Therefore, this article proposes a scoring system, the root coverage esthetic score (RES), to assess the esthetic outcomes following root-coverage procedures on Miller Class I and II gingival recession defects through the evaluation of clinical cases.

Patients (aged >18 years) with no systemic disease and exhibiting Miller Class I and II recession defects were referred to the Department of Periodontology, Dental School, University of Florence, for root-coverage procedures.

Following professional oral hygiene procedures/instructions, patients were treated with different root coverage procedures (pedicle flaps, soft tissue grafts, or combinations), according to specific indications.

Patients were recalled 6 months after surgery, and an expert examiner (FC) assessed the final esthetic outcomes using the RES system.

Probing depth, recession depth, and CAL at experimental sites were measured at baseline and 6 months after surgery.

RES System
The RES system evaluated five variables 6 months following surgery: GM- Gingival Margin MTC- Marginal tissue contour STT- Soft tissue texture MGJ- Mucogingival junction alignment, GC- Gingival color

The clinical esthetic evaluation was performed without magnification.

Zero, 3, or 6 points were used for the evaluation of the position of the gingival margin, whereas a score of 0 or 1 point was used for each of the other variables.

GM-- 0 points = failure of root coverage (gingival margin apical or equal to the baseline recession) 3 points = partial root coverage; 6 points = CRC.

MTC-- 0 points = irregular gingival margin (does not follow the CEJ) 1 point= proper marginal contour/scalloped gingival margin (follows the CEJ).

STT--0 points = scar formation and/or keloidlike appearance. 1 point = absence of scar or keloid formation. MGJ 0 points =MGJ not aligned with the MGJ of adjacent teeth 1 point = MGJ aligned with the MGJ of adjacent teeth.

GC-- 0 points = color of tissue varies from gingival color at adjacent teeth. 1 point = normal color and integration with the adjacent soft tissues.

Thus, the ideal esthetic score was 10.

Zero points were assigned if the final position of the gingival margin was equal or apical to the previous recession depth (failure of root coverage procedure), irrespective of color, the presence of a scar, MTC, or MGJ.

Zero points were also assigned when a partial or total loss of interproximal papilla (black triangle) occurred following the treatment.

Thirty-one patients, 11 males and 20 females mean age, 32 years)who were treated by root-coverage procedures at the Department of Periodontology, Dental School, University of Florence, were enrolled in this study.

RES was used to evaluate the esthetic outcomes of treatment 6 months after surgery.

The mean baseline gingival recession was 3.38 1.08 mm (range, 2 to 6 mm). The mean amount of root coverage was 89.4% (range, 0% to 100%). Twenty-four recession defects (77%) exhibited CRC. The mean RES was 7.8 (range, 0 to 10); only five cases of CRC (16%) achieved RES = 10. In one case (patient 29), RES = O.

Patient I. A) A 3-mm gingival recession at the maxillary right cuspid. B) One millimeter of residual gingival recession 6 months following therapy. The final RES value is 7 (partial root coverage = 3; scalloped gingival margin = I; absence of scar formation = I; MGJ parallel to the gingival margin = I; normal color = I).

Patient 2. A) A3-mm gingival recession at the maxillary left cuspid. B) CRC 6 months following therapy. The final RES value is 10 (CRC = 6; scalloped gingival margin = I; absence of scar formation = I; MGJ parallel to the gingival margin = I; normal color = I).

Patient 7, A) A 3-mm gingival recession at the maxillary left cuspid associated with root/enamel abrasion, B) CRC 6 months following therapy. The final RES is 6. (CRC = 6; irregular/flat gingival margin =0; presence of scar formation =0; MGJ not aligned =0; color alteration =0),

Patient 8, A) A4-mm gingival recession at the upper left cuspid. B) CRC 6 months following therapy. The final RES is 8 (CRC =6; scalloped gingival margin = I; presence of scar formation =0; MGJ not aligned = 0; normal color = I),

Patient 5, A) A3-mm gingival recession at the upper left cuspid. B) CRC 6 months later. The final RES is 7 (CRC =6; scalloped gingival margin = I; presence of scar formation =0; MGJ not aligned=0; color alteration = 0),

Patient I 7. A) A 4-mm gingival recession at the mandibular right lateral incisor. B) CRC 6 months following therapy The Final RES is 8 (CRC = 6; scalloped gingival margin = I; presence of scar formation 0; MGJ not aligned = 0; normal color = I).

Patient 4. A) A3-mm gingival recession at the upper left cuspid. B) CRC 6 months following therapy The final RES is 9 (CRC = 6; scalloped gingival margin = I; absence of scar formation = I; MGJ parallel to the gingival margin = I; color alteration =0).

Patient 29. A) A3-mm gingival recession at the upper left cuspid. B) Six months following therapy: Failure of the root-coverage procedure (gingival margin apical to the baseline recession). Final RES is 0.

The surgical treatment of gingival recessions is performed for esthetic and functional reasons: the final outcome should satisfy patients and clinicians. Nevertheless, esthetic satisfaction following rootcoverage procedure is seldom investigated in clinical trials. Because the esthetic evaluation is influenced by subjective perceptions by both patients and clinicians, an attempt to categorize esthetic assessments can be useful in the evaluation of root-coverage outcomes.

The evaluation period used in this study was 6 months from the last surgical treatment because this period is considered adequate to provide soft tissue maturity and stability as reported in systematic reviews dealing with root-coverage procedures. However, the RES system may be used at different times to assess possible soft tissue modifications during the healing phase, such as creeping attachment . This assessment does not consider the type of procedure used, nor does it evaluate probing depth or

Most clinical cases (24 of 31) achieved CRC (gold standard of treatment) at the 6month follow-up: only five achieved the highest RES (10 points), demonstrating a perfect reconstruction of the treated area. Conversely, several cases showing CRC did not attain a perfect score because of poor tissue integration. Therefore, the final esthetic goal of a root-coverage procedure should shift from the achievement of CRC toward CRC associated with complete soft tissue integration.

The use of microsurgical instruments and smaller sutures may lead to more sophisticated soft tissue handling, thereby enhancing the final esthetic outcomes.

Burkhardt R, Lang NP has demonstrated that in root surface coverage, a microsurgical approach substantially improved the vascularization of the grafts and the percentages of root coverage compared with applying a conventional macroscopic approach. J Clin Periodontal 2005;32:287293 Further studies are needed to validate RES for its

The RES system may be a useful tool for assessing the esthetic outcome following rootcoverage procedures.