Skip to main content

Advertisement

SpringerLink
Log in

Difficulty score for the treatment of isolated gingival recessions with the coronally advanced flap: a preliminary reliability study

  • Original Article
  • Published:
Clinical Oral Investigations Aims and scope Submit manuscript

Abstract

Objectives

The treatment of gingival recessions (GRs) is operator-sensitive and dependent upon several local anatomical factors. The aim of this study was to introduce a difficulty score for the treatment of localized GRs with the coronally advanced flap (CAF) and to test its consistency among different operators.

Materials and methods

A rubric (difficulty score) consisting of the assessment and grading of 8 anatomical parameters (anatomical papilla, apical and lateral keratinized tissue width, apical and lateral frenum, vestibulum depth, scar tissue, and mucosal invagination) is described based on the available evidence and the authors’ experience. Inter-examiner agreement, with the score, was tested on 32 localized GRs among four different experienced practitioners.

Results

Minor discrepancies were observed in the total scores between the reviewers (intraclass correlation coefficient [ICC] 0.95). A good reproducibility, with ICCs ranging from 0.56 to 0.98, was found for the individual parameters. All models showed high absolute variance contribution conveying true differences among the cases, and small examiner variance, demonstrating minor systematic variability among the four reviewers and reproducible evaluations.

Conclusions

The proposed difficulty score for the treatment of GRs with CAF was reproducible among different operators. Clinical interventional studies are the next step to validate the clinical magnitude of the present score.

Clinical relevance

A novel tool for evaluating the difficulty of the treatment of isolated gingival recession using CAF was described. Clinicians can benefit from this score when assessing the expected level of complexity of the surgical case.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

Data available on request from the authors.

References

  1. Cortellini P, Bissada NF (2018) Mucogingival conditions in the natural dentition: narrative review, case definitions, and diagnostic considerations. J Periodontol 89(Suppl 1):S204–S213. https://doi.org/10.1002/JPER.16-0671

    Article  Google Scholar 

  2. Serino G, Wennstrom JL, Lindhe J, Eneroth L (1994) The prevalence and distribution of gingival recession in subjects with a high standard of oral hygiene. J Clin Periodontol 21:57–63

    Article  Google Scholar 

  3. Rios FS, Costa RS, Moura MS, Jardim JJ, Maltz M, Haas AN (2014) Estimates and multivariable risk assessment of gingival recession in the population of adults from Porto Alegre, Brazil. J Clin Periodontol 41:1098–1107. https://doi.org/10.1111/jcpe.12303

    Article  Google Scholar 

  4. Romandini M, Soldini MC, Montero E, Sanz M (2020) Epidemiology of mid-buccal gingival recessions in NHANES according to the 2018 World Workshop Classification System. J Clin Periodontol 47:1180–1190. https://doi.org/10.1111/jcpe.13353

    Article  Google Scholar 

  5. Zucchelli G, Tavelli L, McGuire MK, Rasperini G, Feinberg SE, Wang HL, Giannobile WV (2020) Autogenous soft tissue grafting for periodontal and peri-implant plastic surgical reconstruction. J Periodontol 91:9–16. https://doi.org/10.1002/JPER.19-0350

    Article  Google Scholar 

  6. Barootchi S, Tavelli L, Zucchelli G, Giannobile WV, Wang HL (2020) Gingival phenotype modification therapies on natural teeth: a network meta-analysis. J Periodontol 91:1386–1399. https://doi.org/10.1002/JPER.19-0715

    Article  Google Scholar 

  7. Tavelli L, Barootchi S, Cairo F, Rasperini G, Shedden K, Wang HL (2019) The effect of time on root coverage outcomes: a network meta-analysis. J Dent Res 98:1195–1203. https://doi.org/10.1177/0022034519867071

    Article  Google Scholar 

  8. Tavelli L, Barootchi S, Rodriguez MV, Mancini L, Majzoub J, Travan S, Sugai J, Chan HL, Kripfgans O, Wang HL, Giannobile WV (2022) Recombinant human platelet-derived growth factor improves root coverage of a collagen matrix for multiple adjacent gingival recessions: a triple-blinded, randomized, placebo-controlled trial. J Clin Periodontol. https://doi.org/10.1111/jcpe.13706

    Article  Google Scholar 

  9. Tavelli L, Barootchi S, Nguyen TVN, Tattan M, Ravida A, Wang HL (2018) Efficacy of tunnel technique in the treatment of localized and multiple gingival recessions: a systematic review and meta-analysis. J Periodontol 89:1075–1090. https://doi.org/10.1002/JPER.18-0066

    Article  Google Scholar 

  10. Cairo F, Barootchi S, Tavelli L, Barbato L, Wang HL, Rasperini G, Graziani F, Tonetti M (2020) Aesthetic-and patient-related outcomes following root coverage procedures: a systematic review and network meta-analysis. J Clin Periodontol 47:1403–1415. https://doi.org/10.1111/jcpe.13346

    Article  Google Scholar 

  11. Zucchelli G, Mounssif I, Mazzotti C, Stefanini M, Marzadori M, Petracci E, Montebugnoli L (2014) Coronally advanced flap with and without connective tissue graft for the treatment of multiple gingival recessions: a comparative short- and long-term controlled randomized clinical trial. J Clin Periodontol 41:396–403. https://doi.org/10.1111/jcpe.12224

    Article  Google Scholar 

  12. de Sanctis M, Clementini M (2014) Flap approaches in plastic periodontal and implant surgery: critical elements in design and execution. J Clin Periodontol 41(Suppl 15):S108–S122. https://doi.org/10.1111/jcpe.12189

    Article  Google Scholar 

  13. Zucchelli G, Tavelli L, Barootchi S, Stefanini M, Rasperini G, Valles C, Nart J, Wang HL (2019) The influence of tooth location on the outcomes of multiple adjacent gingival recessions treated with coronally advanced flap: a multicenter re-analysis study. J Periodontol 90:1244–1251. https://doi.org/10.1002/JPER.18-0732

    Article  Google Scholar 

  14. Zucchelli G, Tavelli L, Barootchi S, Stefanini M, Wang HL, Cortellini P (2020) Clinical remarks on the significance of tooth malposition and papillae dimension on the prediction of root coverage. Int J Periodontics Restorative Dent 40:795–803

    Article  Google Scholar 

  15. Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr HF, Mayer ET (2001) Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. J Periodontol 72:998–1005. https://doi.org/10.1902/jop.2001.72.8.998

    Article  Google Scholar 

  16. Ozcelik O, Seydaoglu G, Haytac MC (2015) Prediction of root coverage for single recessions in anterior teeth: a 6-month study. J Clin Periodontol 42:860–867. https://doi.org/10.1111/jcpe.12449

    Article  Google Scholar 

  17. Hwang D, Wang HL (2006) Flap thickness as a predictor of root coverage: a systematic review. J Periodontol 77:1625–1634. https://doi.org/10.1902/jop.2006.060107

    Article  Google Scholar 

  18. Zucchelli G, Testori T, De Sanctis M (2006) Clinical and anatomical factors limiting treatment outcomes of gingival recession: a new method to predetermine the line of root coverage. J Periodontol 77:714–721. https://doi.org/10.1902/jop.2006.050038

    Article  Google Scholar 

  19. Lacour-Gayet F, Clarke D, Jacobs J, Comas J, Daebritz S, Daenen W, Gaynor W, Hamilton L, Jacobs M, Maruszsewski B, Pozzi M, Spray T, Stellin G, Tchervenkov C, Mavroudis C, Aristotle C (2004) The Aristotle score: a complexity-adjusted method to evaluate surgical results. Eur J Cardiothorac Surg 25:911–24. https://doi.org/10.1016/j.ejcts.2004.03.027

    Article  Google Scholar 

  20. Elattar MA, Kaya A, Planken NR, Baan J, Vanbavel ET, de Mol B, Marquering HA (2018) A computed tomography-based planning tool for predicting difficulty of minimally invasive aortic valve replacement. Interact Cardiovasc Thorac Surg. https://doi.org/10.1093/icvts/ivy128

    Article  Google Scholar 

  21. Halls MC, Berardi G, Cipriani F, Barkhatov L, Lainas P, Harris S, D’Hondt M, Rotellar F, Dagher I, Aldrighetti L, Troisi RI, Edwin B, Abu Hilal M (2018) Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection. Br J Surg. https://doi.org/10.1002/bjs.10821

    Article  Google Scholar 

  22. Ma BL, Yao L, Yu W, Wang Y, Song HF, Zhang ZN, Lu SM, Zhang Q, He ZS, Jin J, Zhou LQ (2018) The Institute of Urology, Peking University prostatectomy score: a simple preoperative classification of prostate cancer for predicting surgical difficulty and risk. Asian J Androl 20:581–586. https://doi.org/10.4103/aja.aja_39_18

    Article  Google Scholar 

  23. Atallah MM, Demian AD, Shorrab AA (2004) Development of a difficulty score for spinal anaesthesia. Br J Anaesth 92:354–360. https://doi.org/10.1093/bja/aeh073

    Article  Google Scholar 

  24. Nderitu P, Ursell P (2018) Updated cataract surgery complexity stratification score for trainee ophthalmic surgeons. J Cataract Refract Surg 44:709–717. https://doi.org/10.1016/j.jcrs.2018.04.036

    Article  Google Scholar 

  25. Testori T, Yu SH, Tavelli L, Wang HL (2020) Perforation risk assessment in maxillary sinus augmentation with lateral wall technique. Int J Periodontics Restorative Dent 40:373–380. https://doi.org/10.11607/prd.4179

    Article  Google Scholar 

  26. Testori T, Tavelli L, Yu SH, Scaini R, Darnahal A, Wallace SS, Wang HL (2020) Maxillary sinus elevation difficulty score with lateral wall technique. Int J Oral Maxillofac Implants 35:631–638. https://doi.org/10.11607/jomi.8034

    Article  Google Scholar 

  27. Heath EM, English JD, Johnson CD, Swearingen EB, Akyalcin S (2017) Perceptions of orthodontic case complexity among orthodontists, general practitioners, orthodontic residents, and dental students. Am J Orthod Dentofacial Orthop 151:335–341. https://doi.org/10.1016/j.ajodo.2016.06.045

    Article  Google Scholar 

  28. Stacchi C, Daugela P, Berton F, Lombardi T, Andriulionis T, Perinetti G, Di Lenarda R and Juodzbalys G (2018) A classification for assessing surgical difficulty in the extraction of mandibular impacted third molars: description and clinical validation. Quintessence Int:1–9. https://doi.org/10.3290/j.qi.a40778

  29. Llewellyn SK, Hamdan AM, Rock WP (2007) An index of orthodontic treatment complexity. Eur J Orthod 29:186–192. https://doi.org/10.1093/ejo/cjl080

    Article  Google Scholar 

  30. Correia A, Rebolo A, Azevedo L, Polido W, Rodrigues PP (2020) SAC assessment tool in implant dentistry: evaluation of the agreement level between users. Int J Oral Maxillofac Implants 35:990–994. https://doi.org/10.11607/jomi.8023

    Article  Google Scholar 

  31. Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U (2011) The interproximal clinical attachment level to classify gingival recessions and predict root coverage outcomes: an explorative and reliability study. J Clin Periodontol 38:661–666. https://doi.org/10.1111/j.1600-051X.2011.01732.x

    Article  Google Scholar 

  32. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA (2014) Standards for reporting qualitative research: a synthesis of recommendations. Acad Med 89:1245–1251. https://doi.org/10.1097/ACM.0000000000000388

    Article  Google Scholar 

  33. Zucchelli G, Mele M, Stefanini M, Mazzotti C, Marzadori M, Montebugnoli L, de Sanctis M (2010) Patient morbidity and root coverage outcome after subepithelial connective tissue and de-epithelialized grafts: a comparative randomized-controlled clinical trial. J Clin Periodontol 37:728–738. https://doi.org/10.1111/j.1600-051X.2010.01550.x

    Article  Google Scholar 

  34. Cairo F, Cortellini P, Pilloni A, Nieri M, Cincinelli S, Amunni F, Pagavino G, Tonetti MS (2016) Clinical efficacy of coronally advanced flap with or without connective tissue graft for the treatment of multiple adjacent gingival recessions in the aesthetic area: a randomized controlled clinical trial. J Clin Periodontol 43:849–856. https://doi.org/10.1111/jcpe.12590

    Article  Google Scholar 

  35. Zucchelli G, Mounssif I (2015) Periodontal plastic surgery. Periodontol 2000 68:333–368. https://doi.org/10.1111/prd.12059

    Article  Google Scholar 

  36. Stefanini M, Mounssif I, Marzadori M, Mazzotti C, Mele M, Zucchelli G (2021) Vertically coronally advanced flap (V-CAF) to increase vestibule depth in mandibular incisors. Int J Periodontics Restorative Dent 41:325–333. https://doi.org/10.11607/prd.4925

    Article  Google Scholar 

  37. Barootchi S, Tavelli L, Di Gianfilippo R, Byun HY, Oh TJ, Barbato L, Cairo F, Wang HL (2019) Long term assessment of root coverage stability using connective tissue graft with or without an epithelial collar for gingival recession treatment. A 12-year follow-up from a randomized clinical trial. J Clin Periodontol 46:1124–1133. https://doi.org/10.1111/jcpe.13187

    Article  Google Scholar 

  38. Blasi G, Monje A, Munoz-Penalver J, Oates TW, Avila-Ortiz G, Nart J (2022) Influence of vestibular depth on the outcomes of root coverage therapy: a prospective case series study. J Periodontol. https://doi.org/10.1002/JPER.21-0638

    Article  Google Scholar 

  39. Barootchi S, Tavelli L, Di Gianfilippo R, Shedden K, Oh TJ, Rasperini G, Neiva R, Giannobile WV, Wang HL (2022) Soft tissue phenotype modification predicts gingival margin long-term (10-year) stability: longitudinal analysis of six randomized clinical trials. J Clin Periodontol. https://doi.org/10.1111/jcpe.13641

    Article  Google Scholar 

  40. Zucchelli G, Tavelli L, Stefanini M, Barootchi S, Wang HL (2021) The coronally advanced flap technique revisited: Treatment of peri-implant soft tissue dehiscences. Int J Oral Implantol (Berl) 14:351–365

    Google Scholar 

  41. Naimer SA, Israel A, Gabbay A (2021) Significance of the tethered maxillary frenulum: a questionnaire-based observational cohort study. Clin Exp Pediatr 64:130–135. https://doi.org/10.3345/cep.2020.00486

    Article  Google Scholar 

  42. Zucchelli G, Barootchi S, Tavelli L, Stefanini M, Rasperini G, Wang HL (2021) Implant soft tissue Dehiscence coverage Esthetic Score (IDES): a pilot within- and between-rater analysis of consistency in objective and subjective scores. Clin Oral Implants Res 32:349–358. https://doi.org/10.1111/clr.13706

    Article  Google Scholar 

  43. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174

    Article  Google Scholar 

  44. Liljequist D, Elfving B, Skavberg Roaldsen K (2019) Intraclass correlation - a discussion and demonstration of basic features. PLoS ONE 14:e0219854. https://doi.org/10.1371/journal.pone.0219854

    Article  Google Scholar 

  45. Koo TK, Li MY (2016) A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 15:155–163. https://doi.org/10.1016/j.jcm.2016.02.012

    Article  Google Scholar 

  46. Signorell A (2019) DescTools: tools for descriptive statistics

  47. Kuznetsova AB, Bruckhoff PB, Christensen RHB (2017) lmerTest Package: tests in linear mixed effects models. J Stat Softw 82:1–26. https://doi.org/10.18637/jss.v082.i13

    Article  Google Scholar 

  48. Eddelbuette D (2013) Seamless R and C++ Integration with Rcpp. Springer, New York

    Book  Google Scholar 

  49. Eddelbuette D, Balamuta JJ (2017) Extending R with C++: a brief introduction to Rcpp. PeerJ Preprints 5:e3188v1. https://doi.org/10.7287/peerj.preprints.3188v1

    Article  Google Scholar 

  50. Bürkner PC (2017) brms: an R package for bayesian multilevel models using stan. J Stat Softw 80:1–28. https://doi.org/10.18637/jss.v080.i01

    Article  Google Scholar 

  51. Bürkner PC (2018) Advanced Bayesian multilevel modeling with the R package brms. R J 10:395–411. https://doi.org/10.32614/RJ-2018-017

    Article  Google Scholar 

  52. Wickham HHL (2020) tidyr: tidy messy data

  53. Kay M (2020) tidybayes: tidy data and geoms for Bayesian models

  54. Maruthappu M, Gilbert BJ, El-Harasis MA, Nagendran M, McCulloch P, Duclos A, Carty MJ (2015) The influence of volume and experience on individual surgical performance: a systematic review. Ann Surg 261:642–647. https://doi.org/10.1097/SLA.0000000000000852

    Article  Google Scholar 

  55. Cortellini P, Tonetti M, Baldi C, Francetti L, Rasperini G, Rotundo R, Nieri M, Franceschi D, Labriola A, Prato GP (2009) Does placement of a connective tissue graft improve the outcomes of coronally advanced flap for coverage of single gingival recessions in upper anterior teeth? A multi-centre, randomized, double-blind, clinical trial. J Clin Periodontol 36:68–79. https://doi.org/10.1111/j.1600-051X.2008.01346.x

    Article  Google Scholar 

  56. Tavelli L, Ravida A, Lin GH, Del Amo FS, Tattan M, Wang HL (2019) Comparison between Subepithelial Connective Tissue Graft and De-epithelialized Gingival Graft: a systematic review and a meta-analysis. J Int Acad Periodontol 21:82–96

    Google Scholar 

  57. Chambrone L, Pini Prato GP (2019) Clinical insights about the evolution of root coverage procedures: the flap, the graft, and the surgery. J Periodontol 90:9–15. https://doi.org/10.1002/JPER.18-0281

    Article  Google Scholar 

  58. Cairo F, Rotundo R, Miller PD, Pini Prato GP (2009) Root coverage esthetic score: a system to evaluate the esthetic outcome of the treatment of gingival recession through evaluation of clinical cases. J Periodontol 80:705–710. https://doi.org/10.1902/jop.2009.080565

    Article  Google Scholar 

Download references

Funding

The work was self-supported. 

Author information

Authors and Affiliations

  1. Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy

    Martina Stefanini, Matteo Marzadori, Claudio Mazzotti, Ilham Mounssif, Matteo Sangiorgi & Giovanni Zucchelli

  2. Department of Periodontics & Oral Medicine, University of Michigan School of Dentistry, 1011 N University Avenue, Ann Arbor, MI, USA

    Shayan Barootchi, Lorenzo Tavelli, Hamoun Sabri, Hom-Lay Wang & Giovanni Zucchelli

  3. Department of Oral Medicine, Infection, and Immunity, Division of Periodontology, Harvard School of Dental Medicine, Boston, MA, USA

    Lorenzo Tavelli

Authors
  1. Martina Stefanini
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shayan Barootchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lorenzo Tavelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Matteo Marzadori
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Claudio Mazzotti
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ilham Mounssif
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Matteo Sangiorgi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Hamoun Sabri
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Hom-Lay Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Giovanni Zucchelli
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MS is involved in the conception and design of the study, initial and final drafting of the work, and final approval of the version to be published and accountable for all aspects of the work. SB is involved in the conception and design of the study, analysis and interpretation of data, initial and final drafting of the work, and final approval of the version to be published and accountable for all aspects of the work. LT is involved in the conception and design of the study, initial and final drafting of the work, and final approval of the version to be published and accountable for all aspects of the work. MM, CM, IM, MS, HS are involved in the study measurements, initial and final drafting of the work, final approval of the version to be published, and accountable for all aspects of the work. HLW is involved in the design of the study, critical review of the draft of the manuscript, final review, and approval of the work and accountable for all aspects. GZ is involved in the conception and design of the study, critical review of the draft of the manuscript, final review, and approval of the work and accountable for all aspects.

Corresponding author

Correspondence to Shayan Barootchi.

Ethics declarations

Ethical approval

This study was approved by the Ethical Committee AVEC (253–2020-OSS-AUSLBO).

Consent to participate

The subjects participating in the study were volunteers and provided signed informed consent.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 21 KB)

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Stefanini, M., Barootchi, S., Tavelli, L. et al. Difficulty score for the treatment of isolated gingival recessions with the coronally advanced flap: a preliminary reliability study. Clin Oral Invest 27, 559–569 (2023). https://doi.org/10.1007/s00784-022-04750-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00784-022-04750-0

Keywords

Search

Navigation