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Gingival recession classifications

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In periodontology, classifications are widely used to categorize defects due to periodontitis according to their etiology, diagnosis, treatment and prognosis. …

In periodontology, classifications are widely used to categorize defects due to periodontitis according to their etiology, diagnosis, treatment and prognosis.
Several classifications have been proposed in the literature in order to facilitate the diagnosis of gingival recessions.

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  • 1. Achi Joshi SAIMS, Indore 1
  • 2.   Gingival recession is defined as “the displacement of marginal gingiva apical to the cemento-enamel junction (CEJ).” (American Academy of Periodontology 1992)  The term “marginal tissue recession” is considered to be more accurate than “gingival recession,” since the marginal tissue may have been alveolar mucosa.  Marginal tissue recession is defined as the displacement of the soft tissue margin apical to the cemento-enamel junction (CEJ) (American Academy of Periodontology 1996) INTRODUCTION 2
  • 3.  Classifications, defined as „„systematic arrangements in groups or categories according to established criteria‟‟. (Merriam- Webster 2010)  In periodontology, classifications are widely used to categorize defects due to periodontitis according to their etiology, diagnosis, treatment and prognosis.  Several classifications have been proposed in the literature in order to facilitate the diagnosis of gingival recessions. 3
  • 4.  CLASSIFICATIONS 4
  • 5.   First classification.  Concentrated on recession involving mandibular incisor teeth, used the descriptive terms to classify recession into four groups. • Narrow • Wide • Shallow and • Deep Sullivan and Atkins. (1968) 5
  • 6.  Sullivan and Atkins. (1968) Shallow Deep WideNarrow 6
  • 7.  Reported their results of root coverage with mucosal grafts, quantified  ''shallow-narrow" clefts as being <3 mm in both dimensions,  "deep-wide'" defects as being >3 mm in both dimensions. Mlinek et al (1973) 7
  • 8.   According to their classification,  Visual recession is measured from the cemento- enamel junction to the soft tissue margin.  Hidden recession refers to the loss of attachment within the pocket, i.e., apical to the tissue margin. 8 Liu and Solt (1980)
  • 9. Class I: Marginal tissue recession not extending to the mucogingival junction (MGJ). No loss of interdental bone or soft-tissue. 100% root coverage  Miller (1985) 9
  • 10.  Class II: Marginal recession extending to or beyond the MGJ. No loss of interdental bone or soft-tissue. 100% root coverage. 10
  • 11.   Class III: Marginal tissue recession extends to or beyond the MGJ. Loss of interdental bone or soft-tissue is apical to the CEJ, but coronal to the apical extent of the marginal tissue recession. Partial root coverage 11
  • 12.   Class IV: Marginal tissue recession extends to or beyond the MGJ. Loss of interdental bone extends to a level apical to the extent of the marginal tissue recession. No root coverage . 12
  • 13.   Although Miller‟s classification has been used extensively, there are limitations that need to be considered: Limitations 13
  • 14. 1. The reference point for classification is MGJ. The difficulty in identifying the MGJ creates difficulties in the classification between Class I and II.  There is no mention of presence of keratinized tissue. A certain amount of keratinized gingiva (in the form of free gingiva) will be evident in any tooth with the gingival recession; the marginal tissue recession cannot extend to or beyond the MGJ. In such a case, Class II cannot be a distinct class and Classes I and II would represent a single group. 14
  • 15. 2.In Miller‟s Class III and IV recession, the interdental bone or soft-tissue loss is an important criterion to categorize the recessions.  The amount and type of bone loss has not been specified.  Mentioning Miller‟s Class III and IV doesn‟t exactly specify the level of interdental papilla and amount of loss. A clear picture of severity of recession is hard to project. 15
  • 16.  3. Class III and IV categories of Miller‟s classification stated that marginal tissue recession extends to or beyond the MGJ with the loss of interdental bone or soft-tissue is apical to the CEJ. The cases, which have inter-proximal bone loss and the marginal recession that does not extend to MGJ cannot be classified either in Class I because of inter-proximal bone or in Class III because the gingival margin does not extend to MGJ. 16
  • 17.  4. Miller‟s classification doesn‟t specify facial (F) or lingual (L) involvement of the marginal tissue.  5. Recession of interdental papilla alone cannot be classified according to the Miller‟s classification. It requires the use of an additional classification system. 17
  • 18.  6. Classification of recession on palatal aspect , the difficulty of the applicability of Miller‟s criteria on the palatal aspect of the maxillary arch can be reasoned out to the fact that there is no MGJ on palatal aspect.  Therefore, a classification is required, which specifies the type of recession and can also quantify the amount of loss. The classification should be able to convey the status of the gingival recession and the severity of the condition on palatal aspect. 18
  • 19.  7. Miller‟s classification, estimates the prognosis of root coverage following grafting procedure. Miller stated that 100% coverage can be anticipated in Class I and II recessions, partial root coverage in Class III and no root coverage in Class IV.  This theoretical affirmation is not demonstrated by studies.  Miller also published a case report of an attempt to obtain 100% root coverage in a class IV recession by coronally positioning a previously free gingival graft (Miller & Binkley 1986), 1- year post-operative root coverage was slightly <100% on the facial aspect of the tooth. 19
  • 20.  Smiths, Index of Recession (1997)  Index of Recession. It would have observational and descriptive value, as well as denoting severity and would also provide a basis for evaluating treatment modalities and experimental studies.  Facial and lingual sites of root exposure on the same tooth are assessed separately. The IR being proposed consists of two digits separated by a dash (e.g F2- 4*). The first digit denotes the horizontal and the second the vertical component of a site of recession, with the pre- fixed letter (F or L) denoting whether the recession is on the facial or lingual aspects of the tooth, and an asterisk (*) denoting involvement of the MGJ. 20
  • 21.   0 no clinical evidence of root exposure  1 as 0, but a subjective awareness of dentinal hypersensitivity in response to a 1 second air blast is reported and/or there is clinically detectable exposure of the CEJ for up to 10% of the estimated MM-MD distance: a slit like defect. The horizontal component 21
  • 22.   2 horizontal exposure of the CEJ >10% but not exceeding 25% of the estimated MM-MD distance  3 exposure of the CEJ >25% of the MM-MD distance but not exceeding 50%  4 exposure of the CEJ >50% of the MM-MD distance but not exceeding 75%  5 exposure of the CEJ >75% of the MM-MD distance up to 100% 22
  • 23.  0 no clinical evidence of root exposure  1 as 0, but a subjective awareness of dentinal hypersensitivity is reported and/or there is clinically detectable exposure of the CEJ not extending >1 mm vertically to the gingival margin  2-8 root exposure 2-8 mm extending vertically from the CEJ to the base of the soft tissue defect  9 root exposure >8 mm from the CEJ to the base of the soft tissue defect. The vertical component 23
  • 24.  24 NORLAND AND TARNOW (1998)  Normal interdental papilla fills embrasure space to the apical extent of the interdental contact point/area.  Class I tip of interdental papilla lies between the interdental contact point and most coronal extent of interdental CEJ (space between interproximal CEJ is not visible)  Class II tip of interdental papilla lies at or apical to interproximal CEJ but coronal to apical extent of facial CEJ  Class III the tip of interdental papilla lies level with or apical to facial CEJ
  • 25.   Modifications suggested:  The extent of gingival recession defect in relation to MGJ should be separated from the criteria of bone/soft tissue loss in interdental areas.  Objective criteria should be included to differentiate between the severity of bone /soft tissue loss in class III and class IV  Prognosis assessment must include the profile of the gingiva as thick gingival profile favors treatment outcome and vice versa Mahajan‟s modification of Miller‟s classification (2010) 25
  • 26. An outline of classification system including the above mentioned changes is presented:  Class I GRD not extending to the MGJ.  Class II GRD extending to the MGJ/beyond it.  Class III GRD with bone or soft-tissue loss in the interdental area up to cervical 1/3 of the root surface and/or mal-positioning of the teeth.  Class IV GRD with severe bone or soft- tissue loss in the interdental area greater than cervical 1/3rd of the root surface and/or severe mal-positioning of the teeth. 26
  • 27. Prognosis : BEST Class I and Class II with thick gingival profile. GOOD Class I and Class II with thin gingival profile. FAIR Class III with thick gingival profile. POOR Class III and Class IV with thin gingival profile. 27
  • 28.  Francesco Cairo et al (2011)  Classification based on the assessment of clinical attachment level at both buccal and interproximal sites.  Recession Type 1 (RT1): Gingival recession with no loss of interproximal attachment. Interproximal CEJ was clinically not detectable at both mesial and distal aspects of the tooth 28
  • 29.  Recession Type 2 (RT2): Gingival recession associated with loss of inter- proximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ to the depth of the interproximal pocket) was less than or equal to the buccal attachment loss (measured from the buccal CEJ to the depth of the buccal pocket) 29
  • 30.  Recession Type 3 (RT3): Gingival recession associated with loss of inter- proximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ to the depth of the pocket) was higher than the buccal attachment loss (measured from the buccal CEJ to the depth of the buccal pocket) 30
  • 31.  Most of the classifications of gingival recession are unable to convey all the relevant information related to marginal tissue recession. This information is important for shaping diagnosis, prognosis, treatment planning.  Also, with a broad variety of cases with different clinical presentations, it is not always possible to classify all gingival recession defects according to present classification systems. 31
  • 32.   This classification can be applied for facial surfaces of maxillary teeth and facial and lingual surfaces of mandibular teeth.  Interdental papilla recession can also be classified according to this new classification.  A distinct classification for gingival recession on palatal aspect is also being proposed. New Proposed classification of gingival recession –Dr. ashish kumar et al 32
  • 33. Class I: There is no loss of interdental bone or soft- tissue. This is sub-classified into two categories: Class I-A: Gingival margin on F/L aspect lies apical to CEJ, but coronal to MGJ with attached gingiva present between marginal gingiva and MGJ 33
  • 34. Class I-B: Gingival margin on F/L aspect lies at or apical to MGJ with an absence of attached gingiva between marginal gingiva and MGJ. Either of the subdivisions can be on F or L aspect or both (F and L) 34
  • 35. Class II: The tip of the interdental papilla is located between the interdental contact point and the level of the CEJ mid- buccally/mid- lingually. Interproximal bone loss is visible on the radiograph. This is sub-classified into three categories: Class II-A: There is no marginal tissue recession on F/L aspect. 35
  • 36. Class II-B: Gingival margin on F/L aspect lies apical to CEJ but coronal to MGJ with attached gingiva present between marginal gingiva and MGJ. 36
  • 37. Class II-C: Gingival margin on F/L aspect lies at or apical to MGJ with an absence of attached gingiva between marginal gingiva and MGJ Either of the subdivisions can be on F or L aspect or both (F and L) 37
  • 38. Class III: The tip of the interdental papilla is located at or apical to the level of the CEJ mid-buccally/mid-lingually. Interproximal bone loss is visible on the radiograph. This is sub-classified into two categories: Class III-A: Gingival margin on F/L aspect lies apical to CEJ, but coronal to MGJ with attached gingiva present 38
  • 39. Class III-B: Gingival margin on F/L aspect lies at or apical to MGJ with an absence of attached gingiva between marginal gingiva and MGJ. Either of the subdivisions can be on F or L aspect or both (F and L) 39
  • 40.  Marking guidelines  If a tooth presents marginal tissue recession only on facial (F) or lingual (L) aspect, the class of recession should be followed with the word F or L.  When the gingival margin is coronal to the CEJ, the clinician must detect the CEJ through tactile exploration with the probe tip. The tip of the probe is positioned at 45° angle to the tooth and moved slowly beneath the gingival margin to detect the CEJ with the tactile sensation.  In a case where different levels of recession are observed on the mesial and distal aspects of the same tooth. The use of more apical level of interdental papilla to classify gives a more appropriate idea of severity of the situation. 40
  • 41.   The position of interdental papilla remains the basis of classifying gingival recession on palatal aspect.  The criteria of sub-classifications have been modified to compensate for the absence of MGJ. Classification of palatal gingival recession 41
  • 42.  Palatal recession-I :There is no loss of interdental bone or soft-tissue. This is sub-classified into two categories:  PR-I-A: Marginal tissue recession ≤3 mm from CEJ. 42
  • 43. PR-II-B: Marginal tissue recession of >3 mm from CEJ 43
  • 44. Palatal recession-II The tip of the interdental papilla is located between the interdental contact point and the level of the CEJ mid-palatally. Interproximal bone loss is visible on the radiograph. This is sub-classified into two categories: PR-II-A: Marginal tissue recession ≤3 mm from CEJ. 44
  • 45. PR-II-B: Marginal tissue recession of >3 mm from CEJ 45
  • 46. Palatal recession-III The tip of the interdental papilla is located at or apical to the level of the CEJ mid-palatally. Interproximal bone loss is visible on the radiograph. This is sub-classified into two categories: PR-III-A: Marginal tissue recession ≤3 mm from CEJ. 46
  • 47. PR-III-B: Marginal tissue recession of >3 mm from CEJ 47
  • 48.  Marking guidelines  If marginal tissue recession of 4 mm with no interdental bone loss is present on palatal aspect of maxillary central incisor, it is marked as PR- I-B.  If marginal tissue recession on facial aspect of maxillary central incisor confirms to Class I-A and palatal aspect confirms to PR-I-B, then it should be marked as Class I-A (F) and PR-I-B against that tooth.  In a case where different levels of recession are observed on the mesial and distal aspects of the same tooth. The use of more apical level of interdental papilla to classify gives a more appropriate idea of severity of the situation. 48
  • 49.  Recession status chart 49
  • 50.  The aim of this classification is to answer the pitfalls of the currently used classification systems for recession.  The limitations of Miller‟s classification result in insufficient depiction of clinical condition. Partial depiction leads to an erroneous diagnosis, prognosis, and hence treatment planning.  The criteria suggested in the new classification assist to classify a large number of cases that cannot be distinctly placed into any category according to the current classification systems.  Categorization of recession into groups cannot predict the treatment plan and amount of final root coverage. Discussion 50
  • 51.  The results of various studies, many of which are contrary to the assumptions of Miller, show that categorization in a specific group cannot determine prognosis and treatment plan.  Pini-Prato stated, “The prognostic anticipation of a certain amount of root coverage is a complex process that should consider data from reliable studies and cannot be drawn from theoretical considerations.”  The treatment plan and amount of root coverage not only depends on the clinical condition of the tissues, but also on other prognostic factors  Patient-related factors (e.g., habits)  Tooth/site-related (e.g., recession depth, width)and  Technique-related (e.g., presence or absence of releasing incisions). Mucogingival therapy is very technique sensitive and surgeon‟s dexterity can also affect the extent of root coverage. 51
  • 52. The disease classification should be able to provide clinically beneficial distinctions between conditions that have comparable clinical presentations. Application of more descriptive and detailed classification that requires recording of additional parameters may require additional time, but the clinical picture presented by details would have broader interpretation of recession which would be more beneficial and informative for the clinicians for communication and to arrive at a correct diagnosis. 52
  • 53.  Conclusion  No classification system can be complete and everlasting; with time and its continual use one realizes the advantages and disadvantages of each system.  This classification is a step towards refining the existing drawbacks of the current classification. An attempt has been made so that the new system can be applied to a wider variety of cases to provide more accurate and detailed clinical picture. 53
  • 54.  1. Smith RG. Gingival recession. Reappraisal of an enigmatic condition and a new index for monitoring. J Clin Periodontol 1997;24:201-5. 2. Mahajan A. Mahajan‟s modification of miller‟s classification for gingival recession. Dental Hypotheses 2010;1:45-50. 3. Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol 1998;69:1124-6. 4. Pini-Prato G. The Miller classification of gingival recession: Limits and drawbacks. J Clin Periodontol 2011;38:243-5. 5. Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The interproximal clinical attachment level to classify gingival recessions and predict root coverage outcomes: An explorative and reliability study. J Clin Periodontol 2011;38:661- 6. References 54
  • 55. 55