RESEARCH ARTICLE
Analysis of the Esthetic Outcome after Root Coverage Procedures Using a Comprehensive Approach SUNG MI KIM, DDS, MSD*, YOUN HEE CHOI, DDS, PhD†, YONG GUN KIM, DDS, MSD‡, JIN WOO PARK, DDS, PhD‡, JAE MOK LEE, DDS, PhD‡, JO YOUNG SUH, DDS, PhD‡,§
ABSTRACT Statement of the Problem: There is a reported gap between the relative satisfaction of the clinician and patient after a root coverage procedure. In addition, there may also be a disparity between objective esthetic evaluation tools and subjective satisfaction. Methods: This study included 58 sites in 31 patients who had undergone root coverage procedures. The percentage of root coverage and the root coverage esthetic score system were used as objective measurements. A questionnaire with a five-point ordinal scale was used for subjective evaluation. Initial recession depth and width, Miller classification, tissue biotype, treatment procedures, and follow-up periods were considered as associated factors. Results: After a period of at least 6 months from the procedure, the patient-perceived outcome showed a better match with the root coverage esthetic scoring system than the percentage of root coverage alone. A lower value for objective outcome was obtained for a deeper gingival recession and higher Miller class, but the subjective outcome displayed a steady trend. All four esthetic results were at their lowest after an epithelialized free soft tissue graft. Conclusion: An esthetic outcome according to patient satisfaction was not always consistent with that determined by professional scoring. In addition, partial root coverage may be viewed as a positive outcome by patients and clinicians in cases of deep gingival recession and high Miller class.
CLINICAL SIGNIFICANCE This study evaluates the esthetic outcome of root coverage procedures using an objective method, including the percentage of root coverage, root coverage esthetic scoring system, and subjective assessment by patient and clinician-based questionnaires. The results will be helpful for the understanding of the differences that exist in esthetic satisfaction. (J Esthet Restor Dent 26:107–118, 2013)
INTRODUCTION Prior to the performance of root coverage procedures, it is important for dentists to carefully consider the purpose of the treatment. The reasons that dentists perform the treatment of gingival recession include esthetic issues as well as the reduction of
hypersensitivity.1,2 According to previous reports, the esthetic issue (55–90.7%), which is becoming more stringent, has become the main purpose of root coverage procedures.3–6 If esthetic appearance is now the main concern of patients, an esthetic assessment of the surgical outcome is critical to a proper evaluation of root coverage. A patient-centered study that would
*Clinical instructor, Department of Periodontology, School of Dentistry, Kyungpook National University, Daegu, Korea ‡ Professor, Department of Periodontology, School of Dentistry, Kyungpook National University, Daegu, Korea § Professor, Institute for Hard Tissue and Bio-tooth Regeneration, School of Dentistry, Kyungpook National University, Daegu, Korea † Professor, Department of Preventive Dentistry, School of Dentistry, Kyungpook National University, Daegu, Korea
© 2013 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12085
Journal of Esthetic and Restorative Dentistry
Vol 26 • No 2 • 107–118 • 2014
107
ESTHETIC OUTCOME AFTER ROOT COVERAGE PROCEDURES Kim et al.
allow the determination of the critical esthetic aspects is needed.4,7 Dentists also need to assess the esthetic aspects of results of root coverage that might be different between the patients’ attitudes and the professional rating assessment, which typically excludes certain subjective variables.3 In terms of evaluation tools, complete success was considered to have been attained when the following criteria were satisfied: gingival margin (GM) located at the cement-enamel junction (CEJ) (i.e., complete root coverage), a sulcus depth ≤2 mm, the presence of clinically attached gingiva and no bleeding upon probing of the treated sites.8 The percentage of root coverage can serve as a type of objective and quantitative measurement, and for both periodontists and patients, the greatest success has been reported with complete root coverage.9 On the other hand, an impaired esthetic appearance with scarring and/or a poor color match can sometime occur in the case of complete coverage. Therefore, complete root coverage should not be considered the sole factor for defining the outcome of gingival recession treatment.3 To establish reproducible and reliable methods, a root coverage esthetic scoring system (RES) was introduced for the evaluation of root coverage procedures that is based on an evaluation of five factors: the level of the GM, marginal tissue contour (MTC), soft tissue texture (STT), mucogingival junction alignment (MGJ), and gingival color (GC).10,11 The success of root coverage as determined by objective measurements, including the percentage of root coverage and RES have already been reportedly verified.10–12 However, the relationship between an esthetic evaluation after the performance of a root coverage procedure by a clinician who has a background knowledge of root coverage procedures, and a patient, who is a layperson, has not been established. There might thus be a gap between the satisfaction of the clinician and the patient. In addition, there may also be a disparity between objective esthetic evaluation tools and subjective interpretation. Esthetic satisfaction is affected by cultural background, which is difficult to rate and includes a number of overlapping subjective variables;13 therefore, few studies
108
Vol 26 • No 2 • 107–118 • 2014
Journal of Esthetic and Restorative Dentistry
examining patient esthetic satisfaction have been reported.7 Thus, the aim of this study is to evaluate the esthetic outcome of root coverage procedures by means of a comprehensive approach, using an objective method, including the percentage of root coverage, RES, and subjective assessment as shown by both the patientand clinician-based questionnaires. In examination of factors that differentiate the esthetic outcome, initial recession depth/width, Miller class, tissue biotype, surgical procedures, and follow-up periods were considered.
MATERIALS AND METHODS A total of 31 patients (11 men and 20 women, mean age of 39.6 years, range 23–57 years) who had undergone root coverage procedures for the correction of esthetic problems caused by an exposure of the gingival recession when smiling were recruited for retrospective analysis. The patients had undergone root coverage procedures in the period from 2000 to 2010 in the Department of Periodontology, Kyungpook National University Hospital (KNUH), Daegu, Korea and recruited in 2011 for subsequent analysis. Of these cases, a total of 58 buccal recession defects were selected. According to the definition proposed by Miller, 37 recessions fell into Class I, 12 sites were Class II and the remaining nine recessions were Class III.14 Subjects who agreed to participate in the study signed an informed consent form. The study protocol was reviewed and accepted by the Research Ethics Committee, KNUH (Ethics Reference No. KNUH 2011-11-003). The inclusion criteria were: (1) noncompromised systemic health, 2) nonsmoker, (3) the presence of maxillary or mandibular gingival recession (≥2 mm) classified as Miller class I, II, or III, (4) the presence of identifiable CEJ, (5) the absence of restoration or the presence of superficial caries in the treated areas, (6) good oral hygiene (O’Leary plaque score
Analysis of the Esthetic Outcome after Root Coverage Procedures Using a Comprehensive Approach SUNG MI KIM, DDS, MSD*, YOUN HEE CHOI, DDS, PhD†, YONG GUN KIM, DDS, MSD‡, JIN WOO PARK, DDS, PhD‡, JAE MOK LEE, DDS, PhD‡, JO YOUNG SUH, DDS, PhD‡,§
ABSTRACT Statement of the Problem: There is a reported gap between the relative satisfaction of the clinician and patient after a root coverage procedure. In addition, there may also be a disparity between objective esthetic evaluation tools and subjective satisfaction. Methods: This study included 58 sites in 31 patients who had undergone root coverage procedures. The percentage of root coverage and the root coverage esthetic score system were used as objective measurements. A questionnaire with a five-point ordinal scale was used for subjective evaluation. Initial recession depth and width, Miller classification, tissue biotype, treatment procedures, and follow-up periods were considered as associated factors. Results: After a period of at least 6 months from the procedure, the patient-perceived outcome showed a better match with the root coverage esthetic scoring system than the percentage of root coverage alone. A lower value for objective outcome was obtained for a deeper gingival recession and higher Miller class, but the subjective outcome displayed a steady trend. All four esthetic results were at their lowest after an epithelialized free soft tissue graft. Conclusion: An esthetic outcome according to patient satisfaction was not always consistent with that determined by professional scoring. In addition, partial root coverage may be viewed as a positive outcome by patients and clinicians in cases of deep gingival recession and high Miller class.
CLINICAL SIGNIFICANCE This study evaluates the esthetic outcome of root coverage procedures using an objective method, including the percentage of root coverage, root coverage esthetic scoring system, and subjective assessment by patient and clinician-based questionnaires. The results will be helpful for the understanding of the differences that exist in esthetic satisfaction. (J Esthet Restor Dent 26:107–118, 2013)
INTRODUCTION Prior to the performance of root coverage procedures, it is important for dentists to carefully consider the purpose of the treatment. The reasons that dentists perform the treatment of gingival recession include esthetic issues as well as the reduction of
hypersensitivity.1,2 According to previous reports, the esthetic issue (55–90.7%), which is becoming more stringent, has become the main purpose of root coverage procedures.3–6 If esthetic appearance is now the main concern of patients, an esthetic assessment of the surgical outcome is critical to a proper evaluation of root coverage. A patient-centered study that would
*Clinical instructor, Department of Periodontology, School of Dentistry, Kyungpook National University, Daegu, Korea ‡ Professor, Department of Periodontology, School of Dentistry, Kyungpook National University, Daegu, Korea § Professor, Institute for Hard Tissue and Bio-tooth Regeneration, School of Dentistry, Kyungpook National University, Daegu, Korea † Professor, Department of Preventive Dentistry, School of Dentistry, Kyungpook National University, Daegu, Korea
© 2013 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12085
Journal of Esthetic and Restorative Dentistry
Vol 26 • No 2 • 107–118 • 2014
107
ESTHETIC OUTCOME AFTER ROOT COVERAGE PROCEDURES Kim et al.
allow the determination of the critical esthetic aspects is needed.4,7 Dentists also need to assess the esthetic aspects of results of root coverage that might be different between the patients’ attitudes and the professional rating assessment, which typically excludes certain subjective variables.3 In terms of evaluation tools, complete success was considered to have been attained when the following criteria were satisfied: gingival margin (GM) located at the cement-enamel junction (CEJ) (i.e., complete root coverage), a sulcus depth ≤2 mm, the presence of clinically attached gingiva and no bleeding upon probing of the treated sites.8 The percentage of root coverage can serve as a type of objective and quantitative measurement, and for both periodontists and patients, the greatest success has been reported with complete root coverage.9 On the other hand, an impaired esthetic appearance with scarring and/or a poor color match can sometime occur in the case of complete coverage. Therefore, complete root coverage should not be considered the sole factor for defining the outcome of gingival recession treatment.3 To establish reproducible and reliable methods, a root coverage esthetic scoring system (RES) was introduced for the evaluation of root coverage procedures that is based on an evaluation of five factors: the level of the GM, marginal tissue contour (MTC), soft tissue texture (STT), mucogingival junction alignment (MGJ), and gingival color (GC).10,11 The success of root coverage as determined by objective measurements, including the percentage of root coverage and RES have already been reportedly verified.10–12 However, the relationship between an esthetic evaluation after the performance of a root coverage procedure by a clinician who has a background knowledge of root coverage procedures, and a patient, who is a layperson, has not been established. There might thus be a gap between the satisfaction of the clinician and the patient. In addition, there may also be a disparity between objective esthetic evaluation tools and subjective interpretation. Esthetic satisfaction is affected by cultural background, which is difficult to rate and includes a number of overlapping subjective variables;13 therefore, few studies
108
Vol 26 • No 2 • 107–118 • 2014
Journal of Esthetic and Restorative Dentistry
examining patient esthetic satisfaction have been reported.7 Thus, the aim of this study is to evaluate the esthetic outcome of root coverage procedures by means of a comprehensive approach, using an objective method, including the percentage of root coverage, RES, and subjective assessment as shown by both the patientand clinician-based questionnaires. In examination of factors that differentiate the esthetic outcome, initial recession depth/width, Miller class, tissue biotype, surgical procedures, and follow-up periods were considered.
MATERIALS AND METHODS A total of 31 patients (11 men and 20 women, mean age of 39.6 years, range 23–57 years) who had undergone root coverage procedures for the correction of esthetic problems caused by an exposure of the gingival recession when smiling were recruited for retrospective analysis. The patients had undergone root coverage procedures in the period from 2000 to 2010 in the Department of Periodontology, Kyungpook National University Hospital (KNUH), Daegu, Korea and recruited in 2011 for subsequent analysis. Of these cases, a total of 58 buccal recession defects were selected. According to the definition proposed by Miller, 37 recessions fell into Class I, 12 sites were Class II and the remaining nine recessions were Class III.14 Subjects who agreed to participate in the study signed an informed consent form. The study protocol was reviewed and accepted by the Research Ethics Committee, KNUH (Ethics Reference No. KNUH 2011-11-003). The inclusion criteria were: (1) noncompromised systemic health, 2) nonsmoker, (3) the presence of maxillary or mandibular gingival recession (≥2 mm) classified as Miller class I, II, or III, (4) the presence of identifiable CEJ, (5) the absence of restoration or the presence of superficial caries in the treated areas, (6) good oral hygiene (O’Leary plaque score
