Innovations in Periodontics
Clinical and Anatomical Factors Limiting Treatment
Outcomes of Gingival Recession: A New Method to
Predetermine the Line of Root Coverage
G. Zucchelli,* T. Testori, and M. De Sanctis
T
Complete root coverage is not always achievable, he gingival margin is clinically represented by
even in gingival recession with no loss of interproxi- a scalloped line that follows the outline of the
mal attachment and bone. The cemento-enamel junc- cemento-enamel junction (CEJ), 1 to 2 mm
tion is the most widely used referring parameter to coronal to it.1 Gingival recession is an apical shift of
evaluate root coverage results. The aim of the present gingival margin with exposure of the root surface to
study was to describe the most frequent diagnostic the oral cavity.1 Gingival recession may involve one
mistakes that may lead to incomplete root coverage or more tooth surfaces. The objective of mucogin-
in Miller Class I and II gingival recessions and to sug- gival surgery is the treatment of the recession limited
gest a method to predetermine the level/line of root to one surface (generally the buccal one) with no
coverage in non-molar teeth. associated severe attachment loss at the interprox-
The line of root coverage (i.e., the level/line to imal surfaces.
which the soft tissue margin will be positioned after In the literature, gingival recessions have been
the healing process of a root coverage surgical tech- classified into four classes, according to the prog-
nique) was predetermined by calculating the ideal nosis of root coverage.2 In Class I and II gingival
vertical dimension of the interdental papilla of the recessions, there is no loss of interproximal peri-
tooth with the recession defect. This method was ap- odontal attachment, and bone and complete root
plied to 120 recession-type defects affecting non- coverage can be achieved; in Class III, the loss of
molar teeth of 80 young healthy subjects that were interdental periodontal support is mild to moderate,
treated with root coverage surgical procedures over and partial root coverage can be accomplished; in
the last 5 years. All recessions were Miller Class I Class IV, the loss of interproximal periodontal at-
or II and were associated with at least one of the fol- tachment is so severe that no root coverage is
lowing characteristics: 1) traumatic loss of the tip of feasible.
the interdental papilla(e); 2) tooth rotation; 3) tooth In the recent literature,3,4 the root coverage pre-
extrusion with or without occlusal abrasion; and 4) dictability of a mucogingival surgical procedure is
a cervical abrasion defect with no evidence of the measured in terms of the percentage of root cover-
cemento-enamel junction. age (indicating the percentage of the root exposure
The line of root coverage may be considered the that is covered with soft tissues after the healing
clinical cemento-enamel junction because it may period) and the percentage of complete root surface
substitute the anatomic cemento-enamel junction (showing in which percentage of the treated cases
when this is no longer clinically visible on the tooth the soft tissue margin has been repositioned at the
with recession or when the ideal conditions to obtain level of the CEJ). For the correct evaluation of both
complete root coverage are not fully represented. these parameters, it is necessary to recognize the
J Periodontol 2006;77:714-721. CEJ, which anatomically separates the crown from
the root, on the tooth with the recession defect.
KEY WORDS
Therefore, the clinical healing pattern of only those
Cemento-enamel junction; gingival recession; gingival recessions in which the CEJ is clinically
interdental papilla; surgery. detectable could be evaluated in terms of percentage
and/or complete root coverage. When the CEJ is not
recognizable, it is no longer possible to measure the
depth (and width) of the recession or to assess the
* Department of Odontostomatology, Bologna University, Bologna, Italy.
Department of Periodontology and Implantology, Milan University, Milan,
Italy.
Department of Periodontology, Siena University, Siena, Italy. doi: 10.1902/jop.2006.050038
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J Periodontol April 2006 Zucchelli, Testori, De Sanctis
efficacy of a surgical technique in terms of root quently confused with the anatomic CEJ (Fig. 1A).
coverage, due to the lack of the referring parameter. This error in the localization of the CEJ leads to other
The international literature has thoroughly docu- measurement mistakes, obviously making the de-
mented that gingival recession can be successfully sired root coverage unobtainable. In fact, the patient
treated by several surgical procedures,1,3 irrespec- hopes for a complete coverage of the exposed
tive of the technique used, provided that the fol- dentin, but this result is not achievable because the
lowing biologic conditions for accomplishing root most coronal portion of the exposed dentin belongs
coverage are satisfied: no loss of interdental soft and to the anatomic tooth crown, and thus it is not
hard tissue height.2 coverable with the soft tissues. Post-surgical dentin
However, some surgical approaches have been exposure may be erroneously considered a failure
reported to be more predictable compared to others (or incomplete success) of the root coverage surgi-
in terms of root coverage:3,4 these are the coronally cal technique (Fig. 1B).
advanced flap (CAF) and the bilaminar techniques.5 To avoid this mistake, the clinician must carefully
Even for these procedures, a great variability of observe the outline of the line he/she considers to be
clinical outcomes does exist, and data expressed in the anatomic CEJ. In fact, this line has a curved,
terms of complete root coverage are always quite far convex outline, more or less scalloped, according to
from the desired 100%.3,4 It could be argued that the patients biotype. On the contrary, in the great
some presumed failures (or incomplete successes) majority of cases, the abrasion lines are flat.
in terms of root coverage could be ascribed to The differential diagnosis between abrasion line
mistakes in the selection of the clinical case or of the and anatomic CEJ is often more difficult in posterior
referring measurement parameters rather than to the teeth (premolar and molar), which are characterized
inefficacy of the surgical technique. by a flatter outline of the CEJ even in a thin and
The aim of the present study was to identify some scalloped patients biotype. Nevertheless, a careful
of the most frequent diagnostic mistakes leading observation (better with magnification lenses) will
to incomplete root coverage in Miller2 Class I and II allow the clinician to distinguish the straight (some-
gingival recessions and to suggest a method to times concave) outline of the abrasion line from the
predetermine the position of the soft tissue margin more scalloped and convex outline of the anatomic
after a mucogingival surgical procedure. CEJ.
Mistakes in the Selection of the Clinical Case
Mistakes in Selection of Reference
The following local conditions at the tooth with the
Measurement Parameters
recession defect may limit root coverage even in the
The most frequent mistake in the selection of the
reference parameters concerns the localization of the
anatomic CEJ on the tooth with the recession defect.
In a recent analysis (our unpublished data) on 900
teeth with gingival recession (360 patients), the CEJ
was completely detectable in 30% and partially
recognizable in 25% of the selected cases. Therefore,
there was no sign left of the anatomic CEJ in about
half of the examined teeth. In the great majority
(>90%) of these teeth, cervical abrasions were
associated with the recession of the soft tissue
margin. It can be speculated that the etiologic factor,
likely traumatic (toothbrushing trauma), may have
occurred at the cervical region of the tooth, provok-
ing gingival recession initially and tooth abrasion
afterwards. It is highly improbable that the abrasive
trauma was limited to the area of the exposed root. Figure 1.
More probably, the abrasive trauma involved the A) A canine with deep gingival recession and shallow root abrasion.
whole cervical area and, thus, both the enamel and A line (arrow) can be hardly recognized separating the enamel from
the coronally exposed dentin. This line is too flat to be considered the
the root cementum, causing the disappearance of anatomic CEJ, which has disappeared due to the abrasion defect. B)
the anatomic line (CEJ) which separated the crown After the root coverage surgical procedure, the abrasion line (arrow)
from the root. In many cases of gingival recessions is more evident than before the surgery due to chlorhexidine
associated with cervical abrasion, a line separating pigmentation of the exposed (non-coverable) coronal dentin. The
the enamel from the coronal dentin (exposed due to patient may consider the end result as a failure of the surgical
procedure which, conversely, achieved good root coverage.
the abrasion defect) does appear, and this is fre-
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and be parallel to the anatomic CEJ (Fig. 2D), sion line is covered with soft tissues that have been
whereas the root coverage line will be displaced with coronally advanced in excess to compensate the
respect to the anatomic CEJ in the case of greater or post-surgical soft tissue shrinkage. During the first
exclusive loss of one papilla (mesial or distal) (Fig. 3). healing period (15 to 30 days), the coronal dentin is
gradually exposed, and the abrasion area is often
Clinical CEJ Predetermination in a more pigmented than before surgery because of the
Rotated Tooth (Fig. 4) post-surgical use of chlorhexidine therapy (Fig. 1B).
In a rotated tooth, the contact points with adjacent The patient often considers the reappearance of the
teeth are not correct. Thus, the ideal vertical dimen- pigmented area as a surgical failure. Thus, it is very
sion of the papilla cannot be measured at the tooth important to speak to the patient before surgery,
with the recession, but it must be taken at the clarifying that this post-surgical occurrence does not
homologous contralateral tooth (Fig. 4B). Once depend on the faults and/or limits of the procedure
this dimension is measured, it is reported apically but is the consequence of specific clinical conditions
starting from the tip of both anatomic papillae of the (i.e., cervical abrasions) originally present at the tooth
rotated tooth with gingival recession (Fig. 4C). The with the recession defect. Furthermore, the patient
projections of these measurements allow identifica- has to be reassured that the pigmentation of the
tion of two points along the recession margin that are exposed dentin is reversible with the use of simple
connected by the scalloped line of root coverage professional hygienic tools and procedures (polishing
(Fig. 4C). with rubber cup and prophylaxis paste). It is impor-
tant not to underestimate the clinicians ability to
Clinical CEJ Predetermination in an Extruded
predict and inform patients about the post-surgical
Tooth (with or without occlusal abrasion) (Fig. 5)
outcome, even if unfavorable. This ability increases
The measurement of the ideal papilla is performed
the patients trust and esteem in the clinician.
at the adjacent homologous non-extruded tooth
Whenever there is a probability that exposed
(Fig. 5B) (in the case of premolar teeth) or at the
coronal dentin (not coverable with soft tissues)
homologous contralateral tooth. As previously de-
may become an esthetic problem for the patient, it
scribed for the other conditions, the dimension of the
is highly recommended to treat the abrasion area by
ideal papilla is reported apically from the tip of both
means of an esthetic restoration before surgical
anatomic papillae of the extruded tooth with the
treatment of gingival recession. In fact, the presence
recession defect (Fig. 5B). The obtained line of root
of the exposed root surface apical to the abrasion
coverage will be parallel to the anatomic CEJ (if
area facilitates the isolation of the operative field with
recognizable) at a distance from it, which is equal to
a rubber dam, and the identification of the line of root
the amount of tooth extrusion (Fig. 5C).
coverage will provide the restorative dentist with a
guideline for the apical preparation of the composite
DISCUSSION filling.
The predetermination of the line of root coverage A situation similar to this may be verified when
has different clinical applications, which may im- there is a chromatic contrast between the anatomic
prove the final outcome of the mucogingival sur- crown and root in the presence of a Class III gingival
gery, allow for a more esthetic treatment of cervical recession.2 In this case, the periodontal treatment,
abrasion associated with gingival recession, and by itself, cannot satisfy the patients esthetic de-
meet patient demands even when the local condi- mands because it leaves the most coronal (and
tions are not favorable to accomplish a good es- darker) portion of exposed root surface uncovered.
thetic result. Furthermore, the identification of the In such a situation, the apical shift of the CEJ by
clinical CEJ may permit a better evaluation of the means of the composite restoration (made at the
root coverage efficacy of a given surgical proce- level of the line of root coverage) and followed by
dure when the referring anatomical parameters are mucogingival treatment of the coverable portion of
lacking or when the ideal conditions to achieve the exposed root will allow the clinician to reach a
complete root coverage are not fully satisfied (Miller good esthetic result even when the anatomic/bio-
Class III).2 logic conditions to obtain complete root coverage
In a tooth in which the anatomic CEJ is no longer are not fully represented.
discernible due to the presence of an abrasion de- In patients with gingival recessions due to tooth-
fect, a line may become visible in the cervical area brushing trauma, cervical abrasions are frequently
(Fig. 1). This line, which appears due to the exposure associated with the root exposures. In many in-
of coronal dentin (generally darker and more yellow stances, the abrasion involves both the crown and
than the enamel), is frequently mistaken for the the exposed root causing the disappearance of the
anatomic CEJ. At the end of the surgery, the abra- anatomic CEJ (Fig. 7). In this case, restorative
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the presence or absence of the interproximal papilla. type defects. A comparative clinical study. J Clin
J Periodontol 1992;63:995-996. Periodontol 2003;30:862-887.
7. Cardaropoli D, Re S, Corrente G. The papilla presence 11. Zucchelli G, De Sanctis M. Treatment of multiple
index (PPI): A new system to assess interproximal recession type defects in patients with aesthetic de-
papillary levels. Int J Periodontics Restorative Dent mands. J Periodontol 2000;71:1506-1514.
2004;24:488-492. 12. Zucchelli G, Cesari C, Amore C, Montebugnoli L, De
8. Pini Prato GP, Rotundo R, Cortellini P, Tinti C, Azzi R. Sanctis M. Laterally-moved, coronally advanced flap: A
Interdental papilla management: A review and classi- modified surgical approach for isolated recession type
fication of the therapeutic approaches. Int J Periodon- of defects. J Periodontol 2004;75:1734-1741.
tics Restorative Dent 2004;24:246-255.
9. Zucchelli G, Clauser C, De Sanctis M, Calandriello M. Correspondence: Prof. Giovanni Zucchelli, Bologna Uni-
Mucogingival versus GTR procedures in the treatment versity, Department of Odontostomatology, Via S. Vitale
of deep recession type defects. J Periodontol 1998; 59, 40125 Bologna, Italy. Fax: 39-05-1225208; e-mail:
69:138-145. zucchell@alma.unibo.it.
10. Zucchelli G, Amore C, Montebugnoli L, De Sanctis M.
Bilaminar techniques for the treatment of recession Accepted for publication September 26, 2005.
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