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Practical Applications: A New Index Proposed For Determination of Outcome of Recession Coverage Procedures
Practical Applications: A New Index Proposed For Determination of Outcome of Recession Coverage Procedures
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
FIGURE 1 Schematic diagram showing a normally inclined tooth with was required. A dental stone cast was fabricated, and all
adequate thickness of gingiva and alveolar bone (1a) and a proclined tooth
with gingival and alveolar thinning (1b). the measurements were made on this cast. A stainless steel
wire (26 gauge) was adapted, contacting the mesial pit of
coverage therapy.2 Adequate vascular supply is essential to the first permanent molar of one side, passing over the lin-
achieve complete root coverage. This may be obtained gual/palatal cusps of premolars, contacting the cingulum
from the bone, periosteum, and periodontal ligament un- area of anterior teeth, and continuing on the opposite side
derlying the graft and from flap tissue overlying the graft. on the same pattern up to the mesial pit of the opposite first
So, if bone is present apically and is thin, then a lesser permanent molar. Once adapted, the wire was placed on the
amount of blood supply will be available to nourish the arch wire template† (Fig. 2) for standardization of the adap-
overlying flap as well as graft.9 ted wire. The arch wire template is a transparent symmetric
grid made of plastic. On this template, there are three pat-
Effects of Tooth Rotation on Soft- and Hard- terns of arches (both mandibular and maxillary) printed
Tissue Topography (i.e., square, taper, and oval) over which the preadapted wire
can be superimposed (from canine to canine region) to know
The topographic relationship in rotated teeth, between the
the pattern of the arch as well as determine the standardiza-
CEJ and the interdental papilla mesial and distal to a tooth
tion of the adaptation. Proclination (Figs. 3 and 4) and ro-
with recession, changes at one tooth side (mesial or distal
tation (Figs. 5 and 6) of the teeth can be measured with
according to sense of rotation), and the CEJ is closer to
a caliper‡ according to scoring criteria (Table 1).
the tip of the papilla, whereas at the other side it is farther.
Note the following: 1) if the first molar is absent, then the
The situation in which the CEJ is closer to the tip of the an-
distal pit of the second premolar can be used as a reference
atomic papilla causes a loss of papilla height clinically sim-
point for adapting the wire; 2) if both the mesial and distal
ilar to that caused by trauma. The only difference between
line angles of the tooth under consideration are away from
these situations is that one or both of the interdental papilla
the wire to different extents, then the mean of both dis-
can be involved in the case of traumatic loss, whereas in the
tances is taken and scored accordingly under proclination.
case of tooth rotation, the height of only one papilla is re-
duced. Root coverage surgical techniques will leave a por-
Limitations
tion of root surface uncovered at the toothside where
there is reduction of papilla height; this is often erroneously The following are limitations: 1) Only the location of
considered failure of root coverage procedure.1 a tooth in the arch was considered (neither the interprox-
imal bone level nor the soft tissues were considered). These
Comparison of Previous Classifications and are primary predictors11 for success of complete root cov-
Indices erage. The reason was to avoid the exposure of the patient
to x-rays. 2) The ideal method to determine the pattern of
Possibly the first classification of recession by Sullivan and At- teeth in an arch is cephalometric analysis, but this diagnos-
kins in 196810 had a morphologic basis, but it had no predic- tic tool was not used so as to avoid the exposure to x-rays.
tive value regarding treatment outcome.
A landmark classification of recession was given by †
Sym Grid, Desire KDP, Mumbai, India.
Miller in 198511 who enhanced the predictability of root ‡
Vernier, Beaverton, OR.
Score Criteria
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
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-
FIGURE 5 The mesial line angle of teeth #24 and #25 touch the stainless ciently to allow resuming normal oral hygiene measures.
steel wire, whereas the distal line angles are away from stainless steel wire
because of rotation.
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-
FIGURE 6 Schematic diagram showing the relationship of the adapted ularly when associated with predisposing factors such as
wire to rotated teeth #24 and #25. thin gingival biotype, prominent root surface, buccally po-
sitioned teeth, and bony dehiscences.13
Root recession coverage procedures are not very predict-
right angle incisions were made into the adjacent interden-
able. It is important to differentiate between success and pre-
tal papillae mesially and distally to the defect, at or slightly
dictability with regard to root coverage procedures. Success
coronal to the level of the CEJ of the tooth presenting the
of root coverage procedures is related to the average percent-
recession. A sulcular incision was made connecting the hor-
age of root coverage achieved (Table 3), whereas predictabil-
izontal incisions. A partial thickness dissection was then
ity (Table 4) describes the percentage of the treated teeth in
performed extending apically beyond the mucogingival
which complete root coverage is achieved.14
junction and mesiodistally beyond the osseous margins
In our study, we applied the MI to a small population and
of the bony dehiscence. Donor connective tissue with 1-
found there was a correlation between malocclusion and
to 2-mm epithelial collar was harvested from the molar–
premolar area of the palate using two parallel horizontal x
VICRYL 4-0, Ethicon, Johnson & Johnson, Cornelia, GA.
incisions located ‡2 mm apically to the gingival margin k
VICRYL 4-0, Ethicon, Johnson & Johnson.
{
of maxillary teeth. The graft dimensions were determined UNC PCP-15 probe, Hu-Friedy, Chicago, IL.
0.510* 0.015 1
* Correlation is significant at the 0.05 level (two-tailed).
Treatment Modality No. of Studies Mean % of Root Coverage Achieved Range of Root Coverage Achieved
Treatment Modality No. of Studies Mean % of Root Coverage Achieved Range of Root Coverage Achieved
recession coverage obtained after connective tissue graft the tooth was aligned orthodontically within the arch, so
procedures. At six sites, we obtained 100% root coverage, that an MI score of 0 was achieved. After 2 years, the tooth
and the MI score was 0 (Figs. 7a and 7b). At two sites, the was treated with connective tissue graft, obtaining 100%
mean recession coverage obtained was 53.55%, and the root coverage. This particular case further indicates the
MI scores were 6, i.e., severe proclination (Figs. 8a and usefulness of MI and its correlation with the predictability
8b). In one patient, two adjacent sites with MI scores of the outcome of the recession coverage procedures.
0 and 2 (rotation) were treated, and the recession coverage
obtained was 50% and 42.8%, respectively (Figs. 9a and
Conclusion
9b). This suggests that if a malaligned tooth is present with
The present clinical study concludes that the proposed MI
an adjacent properly aligned tooth, it can also affect the
will be of high prognostic value, in predetermination of the
overall recession coverage achieved.
success of the root recession coverage procedures in pro-
In most cases of recession coverage procedures, root con-
clined and rotated teeth. n
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 Acknowledgments
can lead to increased hypersensitivity. This can be avoided No external funding apart from the support of the authors’
if we can predetermine the approximate extent of root cov- institution was provided for this study. The authors report
erage to be obtained after mucogingival procedures. no conflicts of interest related to this study.
During the course of this study, it was observed that one
patient with root recession of 5 mm in teeth #24 and #25 CORRESPONDENCE:
Dr. Nymphea Pandit, Department of Periodontology and Implantology,
with MI scores of 3 was treated with regenerative tissue.# DAV Centenary Dental College and Hospital, Model Town, Yamuna Nagar,
No coverage at all was achieved in this case. Subsequently, 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).
Pandit, Gaba, Malik, Pandit Clinical Advances in Periodontics, Vol. 2, No. 1, February 2012 55