Assessment of various treatment modalities for isolated gingival recession defect - A retrospective study

Esthetic demands among the patients have increased markedly over the past few years. The Gingival recession is one of the prime esthetic concerns, and there are various treatment modalities in managing recession defects. Most often, esthetic outcomes following root coverage procedures are not assessed. Thus the current article aims to determine the aesthetic outcome following various treatment modalities for root coverage procedures using Recession Esthetic Score (RES). In the present study, seventeen patients with Miller Class I, II and III recession defects treated with root coverage procedures were eval-uated retrospectively. Esthetic outcomes were assessed using the root coverage esthetic score (RES) postoperatively. Among 17 managed recession sites, 6(35%) had complete root coverage. Three of six patients who attained complete root coverage had a perfect score (RES-10). Free Gingival Graft showed better root coverage and recession esthetic score (RES); however, there was no signi(cid:977)icant association between root coverage, RES and various treatment modalities used for recession coverage (p>0.05).


INTRODUCTION
Periodontal diseases that have evolved over the years and have transformed from periodontitis being considered an almost ubiquitous condition (Ramamurthy and Mg, 2018). Periodontal disease is a chronic in lammatory disease which is one of the major causes for tooth loss in adults (Varghese, 2015;Mootha et al., 2016;Avinash et al., 2017;Khalid, 2016;Ramesh et al., 2017).
Periodontitis is characterised by a bacterial infec-tion which leads to in lammation of the gums thereby destroying periodontal tissues and alveolar bone Priyanka, 2017;Kumar and Varghese, 2019;Murthykumar et al., 2019). It also results in the breakdown of the collagen ibres of the periodontal ligament, resulting in the periodontal pocket between the gingiva and tooth (Panda, 2014;Khalid, 2016). Periodontal disease is as such a slowly progressing disease, but the tissue destruction is irreversible . Historically treatment of periodontitis has been primarily directed at the elimination of causative factors and maintenance of a functional and healthy dentition (Kavarthapu and Thamaraiselvan, 2018;Ramesh, 2019;Thamaraiselvan et al., 2015). Periodontal therapy includes both surgical and nonsurgical management of disease processes (Ramesh, 2016). Anatomical landmark consideration is essential during periodontal therapy (Kavarthapu and Thamaraiselvan, 2018).
Graph 1 X axis represents the Gingival Colour Score in the scale of 0, 1 and Y axis represents the number of cases; Blue Colour represents FGG (Free Gin- Graph 4 (X axis represents the Soft Tissue Texture Score in the scale of 0,1; Y axis represents the number of cases; Blue Colour represents FGG (Free Gingival Graft); Green Colour represents CTG + Pouch and Tunnel Technique; Cream colour represents CTG (Connective tissue graft) and purple colour represents Laterally displaced lap). FGG had better Soft Tissue Texture Score than other treatment modalities, however it is not statistically signi icant. Chi-square test, Pearson Chi-square value 1.587, p value 0.662 (p>0.05).
Graph 5 (X axis represents the Gingival Margin Score in the scale of 0,3 and 6; Y axis represents the number of cases; Blue Colour represents FGG(Free Gingi- Graph 6 (X axis represents the Root Coverage % ranging 30%-100% ; Y axis represents the number of cases; Blue Colour represents FGG( Free Gingival Graft); Green Colour represents CTG + Pouch and Tunnel Technique; Cream colour represents CTG (Connective tissue graft) and purple colour represents Laterally displaced lap).FGG had better root coverage than other treatment modalities, however it is not statistically signi icant. Chisquare test, Pearson Chi-square value 4.887, p value 0.558(p>0.05).
The gingival recession defect is a primary esthetic concern. Management of recession defects is indicated for esthetic purposes, to overcome dentin sensitivity caused due to the root exposure and to increase the amount of keratinised tissue ('Consen-sus report. Mucogingival therapy ', 1996). Most often the clinical outcomes following the management of recession defects are generally expressed in terms of percentage of root coverage and at times in terms of complete root coverage (Cairo et al., 2008). Patients demand esthetic management has increased over the days; thus, the gingival recession coverage procedure should provide a soft tissue component which is comparable and indistinguishable from adjacent tissue (Miller and Jr, 1985).

MATERIALS AND METHODS
In this retrospective study, 17 patients who had undergone root coverage for isolated gingival recession defects in the Department of Periodontics, Saveetha Dental College from June 2019 to March 2020 were assessed. Scores were given based on the RES to evaluate the esthetic outcome following recession coverage. 5. Patients who underwent any dental treatments in the past six months.

Statistical Analysis
All the data were included in SPSS software IBM version 23.0. The chi-square test was used to analyse the association between RES and various surgical procedures for recession defect. Also, the association between recession coverage and different recession coverage procedures was analysed. A Pvalue of less than 0.05 was considered statistically signi icant.

RESULTS AND DISCUSSION
The current study showed no statistical difference (p>0.05) between RES score and various treatment modality available for recession coverage   (Table 1). There was no signi icant(p>0.005) association among postoperative gingival colour score, mucogingival junction alignment score, marginal tissue contour score, soft tissue texture score, gingival margin score and root coverage in percentage and various treatment modalities available for recession coverage as shown in Graphs 1, 2, 3, 4, 5 and 6.

RES
Esthetic satisfaction following root coverage procedure is most often seldom investigated in clinical trials (Aichelmann-Reidy et al., 2001;Wang, 2001). Esthetic evaluation is more subjective. Thus, esthetic assessment can be useful in the evaluation of recession coverage outcomes.
Present study results showed no statistical signi icance between RES, Root coverage vs various treatment modalities used for recession coverage. Evidence (Cairo, 2009) report that coronally advanced lap for recession coverage had better root coverage and RES compared to other treatment modalities which were contradictory to the present study were Free Gingival Graft had better root coverage and RES score this would be because of the difference in the ethnic group as well due to less sample size in the present study. (Prato and P, 2005) showed that there was 100% recession coverage with coronally advanced lap. In contrast, the same results were not obtained in the present study; this could be because of the clinical case selection as well as surgical techniques used. (Wennstrom and Zucchelli, 1996) in their study also showed that free gingival graft had lower recession coverage among all the recession coverage procedures whereas in our present study free gingival graft showed to have better results though it was statistically not signi icant.
The limitation of the present study was that it had a limited sample size, short term follow up. Hence extensive research should be done with long term follow up and by including other parameters that assess the effectiveness of various treatment modalities of isolated recession defects.

CONCLUSIONS
Free Gingival Graft showed better root coverage and recession esthetic score (RES); however, there was no signi icant association among root coverage, RES and various treatment modalities used for recession coverage (p>0.05). Thus, future studies need to be assessed in larger sample size as well as standardized esthetic outcome measures are required to evaluate recession esthetic scores.