Clinical evaluation of root coverage

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ABSTRACT
Purpose: The aim of current study was to evaluate percentage root coverage (RC%) in isolated 
Miller class III/RT2 labial gingival recession (GR) associated with malaligned mandibular 
anteriors, using interdisciplinary periodontal-orthodontic treatment as compared to 
mucogingival surgery alone.
Methods: Thirty-six systemically healthy patients having isolated Miller class III/RT2 GR 
with respect to malaligned mandibular anteriors, were randomly divided into test group: 
mucogingival surgery using subepithelial connective tissue graft followed by orthodontic 
treatment and control group: mucogingival surgery alone. Primary clinical parameters 
included (RC%), recession depth, keratinized tissue width, mid-labial clinical attachment 
level, interdental clinical attachment level (iCAL), periodontal phenotype (PP), gingival 
thickness (GT), root coverage esthetics score (RES) and hypersensitivity. Total duration of 
follow up was 12 months.
Results: Mean RC% was significantly more achieved in test group (66.67%±40.82%) in 
comparison to control group (39.93%±31.41%) at the end of study (P=0.049). Further, 
complete root coverage was attained in 5/8 cases of test group versus 1/2 cases of control 
group after 3/12 months respectively. RES and hypersensitivity, showed statistically 
significant improvement after complete follow up period in both the groups. An ideal RES 
score of 10 was achieved in 4/7 cases of test group while in 1/2 cases of control group after 
3/12 months respectively. Correlation analysis revealed significant negative correlation 
between RC% and iCAL. Correlation of RC% with GT and PP was non-significant.
Conclusions: Interdisciplinary periodontal-orthodontic approach may be more beneficial 
in terms of achieving improved RC%, esthetic and resolution of hypersensitivity in the 
management of Miller class III/RT2 GR in malaligned mandibular anteriors.
Trial Registration: ClinicalTrials.gov Identifier: NCT04255914
Keywords: Connective tissue; Dentin hypersensitivity; Esthetics; Gingival recession; 
Orthodontics; Phenotype
J Periodontal Implant Sci. 2024 Aug;54(4):265-279
https://doi.org/10.5051/jpis.2204100205
pISSN 2093-2278·eISSN 2093-2286
Received: Oct 13, 2022
Revised: Mar 21, 2023
Accepted: Apr 30, 2023
Published online: Nov 20, 2023
*Correspondence:
Shikha Tewari
Department of Periodontics, Post Graduate 
Institute of Dental Sciences, Pandit Bhagwat 
Dayal Sharma University of Health Sciences, 
Rohtak 124001, India.
Email: drshikhatewari@yahoo.com
Tel: +91 9416514600 
Fax: +91 1262283876
Copyright © 2024. Korean Academy of 
Periodontology
This is an Open Access article distributed 
under the terms of the Creative Commons 
Attribution Non-Commercial License (https://
creativecommons.org/licenses/by-nc/4.0/).
ORCID iDs
Sakshi Malhotra 
https://orcid.org/0000-0002-5056-8791
Shikha Tewari 
https://orcid.org/0000-0002-2659-333X
Rekha Sharma 
https://orcid.org/0000-0001-8065-6584
Rajinder Kumar Sharma 
https://orcid.org/0000-0001-7839-1097
Nishi Tanwar 
https://orcid.org/0000-0001-9469-897X
Ritika Arora 
https://orcid.org/0000-0002-0740-1515
Sakshi Malhotra 1, Shikha Tewari 1,*, Rekha Sharma 2, 
Rajinder Kumar Sharma 1, Nishi Tanwar 1, Ritika Arora 1
1Department of Periodontics, Post Graduate Institute of Dental Sciences, Rohtak, India
2 Department of Orthodontics and Dentofacial Orthopaedics, Post Graduate Institute of Dental Sciences, 
Rohtak, India
Clinical evaluation of root coverage 
in Miller class III/RT2 labial gingival 
recession treated with interdisciplinary 
periodontal-orthodontic therapy: 
a randomized controlled clinical trial
Research Article
https://jpis.org 265
Periodontal Science
http://crossmark.crossref.org/dialog/?doi=10.5051/jpis.2204100205&domain=pdf&date_stamp=2023-11-20
http://clinicaltrials.gov/ct2/show/NCT04255914
https://creativecommons.org/licenses/by-nc/4.0/
https://creativecommons.org/licenses/by-nc/4.0/
https://orcid.org/0000-0002-5056-8791
https://orcid.org/0000-0002-5056-8791
https://orcid.org/0000-0002-2659-333X
https://orcid.org/0000-0002-2659-333X
https://orcid.org/0000-0001-8065-6584
https://orcid.org/0000-0001-8065-6584
https://orcid.org/0000-0001-7839-1097
https://orcid.org/0000-0001-7839-1097
https://orcid.org/0000-0001-9469-897X
https://orcid.org/0000-0001-9469-897X
https://orcid.org/0000-0002-0740-1515
https://orcid.org/0000-0002-0740-1515
https://orcid.org/0000-0002-5056-8791
https://orcid.org/0000-0002-2659-333X
https://orcid.org/0000-0001-8065-6584
https://orcid.org/0000-0001-7839-1097
https://orcid.org/0000-0001-9469-897X
https://orcid.org/0000-0002-0740-1515
Trial Registration
ClinicalTrials.gov Identifier: NCT04255914
Conflict of Interest
No potential conflict of interest relevant to this 
article was reported.
Author Contributions
Conceptualization: Sakshi Malhotra, Shikha 
Tewari, Rekha Sharma; Formal analysis: Shikha 
Tewari, Rekha Sharma; Investigation: Sakshi 
Malhotra, Shikha Tewari, Rekha Sharma, 
Nishi Tanwar; Methodology: Shikha Tewari, 
Rekha Sharma, Rajinder Kumar Sharma, Nishi 
Tanwar, Ritika Arora; Project administration: 
Shikha Tewari, Rekha Sharma; Writing - 
original draft: Sakshi Malhotra, Shikha Tewari, 
Rekha Sharma, Ritika Arora; Writing - review 
& editing: Sakshi Malhotra, Shikha Tewari, 
Rekha Sharma, Rajinder Kumar Sharma, Nishi 
Tanwar, Ritika Arora.
Root coverage in RT2 GR by perio-ortho treatment
https://doi.org/10.5051/jpis.2204100205
INTRODUCTION
Gingival recession (GR) is defined as the migration of the gingiva to a point apical to the 
cementoenamel junction (CEJ) [1]. It has been encountered more frequently in mandibular 
than maxillary teeth and on labial than lingual surfaces [2]. It often causes aesthetic concerns 
[3], dentin hypersensitivity [4], and increased vulnerability to root caries [5].
The main etiologic factors in the pathogenesis of GR are periodontal disease and traumatic 
tooth brushing [2,6]. Besides these factors, various predisposing factors associated with 
GR include labial orthodontic tooth movement [7], bone dehiscence and fenestration [8], 
thin periodontal phenotype (PP) [9], and malposition of the teeth [10]. Prevalence of mid-
buccal RT2 GR was reported to be 88.8% in adult US population, according to the 2017 world 
workshop classification [11].
Complete root coverage (CRC) in Miller class III/RT2 GR is challenging, and various 
techniques for the root coverage in Miller class III/ RT2 GR include coronally advanced flaps 
(CAFs) [12], laterally positioned flaps [13], free gingival grafts (FGG) [14], pouch and tunnel 
approach [15], vestibular incision subperiosteal tunnel access (VISTA) [16], and subepithelial 
connective tissue graft (SCTG) [17].
Tooth malpositioning is a predisposing factor associated with GR [10]. A correlation has 
been reported in a previously conducted study between the percentage root coverage (RC%) 
achieved and malocclusion [18]. In the study, CRC was achieved using SCTG in aligned 
teeth whereas partial root coverage was attained in malaligned teeth having Miller class I or 
II GR. A case report showed that orthodontic treatment after FGG further promoted root 
coverage in Miller class III GR with respect to protruded mandibular central incisor [19]. 
An interventional study conducted by Laursen et al. [20] demonstrated that orthodontic 
treatment led to the conversion of Miller class III GR cases to class I or II GR, and recession 
depth (REC) was reduced.
Therefore, it was hypothesized that in managing Miller class III/RT2 GR where CRC is 
difficult to achieve, an interdisciplinary approach by performing mucogingival surgery 
followed by orthodontic correction would be more beneficial in achieving better outcomes. 
Since there is a paucity of randomized controlled trials studying this aspect; this study was 
designed to evaluate the clinical outcomes in terms of root coverage percentage achieved, 
in isolated Miller class III/RT2 GR in malaligned mandibular anteriors treated by an 
interdisciplinaryapproach.
MATERIALS AND METHODS
Experimental design
The current study was a parallel, randomized clinical trial, and this study was conducted 
according to the guidelines of the Helsinki Declaration of 1975, updated in 2013. The ethical 
approval was obtained from the ethical committee of Post Graduate Institute of Dental 
Sciences (PGIDS/IEC/2019/27) and study protocol was approved by the institutional review 
board of Pt. BD Sharma University of health sciences, Rohtak. This trial was registered at 
ClinicalTrials.gov.with NCT04255914.
https://jpis.org 266
http://clinicaltrials.gov/ct2/show/NCT04255914
http://clinicaltrials.gov/ct2/show/NCT04255914
The study was carried out in the department of Periodontology in association with the 
department of Orthodontics and dentofacial orthopedics, PGIDS, Rohtak. Sixty-eight 
patients were screened from regular out patient department of Periodontology, Orthodontics 
and dentofacial orthopedics, and Oral medicine and radiology. Thirty-six systemically healthy 
patients having isolated GR with respect to malaligned mandibular anteriors, and willing 
for orthodontic treatment, were enrolled for the study. The period of this study was from 
February 2020 to December 2021.
The inclusion criteria were as follows:
• Patients aged 18–35 years.
• An isolated Miller’s class III/RT2 GR, in relation to malaligned mandibular anteriors 
(Figure 1A-C, Figure 2A and B).
• Tooth size-arch length discrepancy ≤4mm, in mandibular anteriors.
• Non-extraction orthodontic cases.
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A B C
E F G
H I J
D
Figure 1. Clinical photographs of test group case. (A) Gingival recession in relation to mandibular left central incisor (#31), at baseline (T0). (B) Incisal view 
showing malaligned #31, at T0. (C) Radiograph showing interdental bone loss in relation to #31. (D) SCTG harvested from palate. (E) Intraoperative image showing 
recession coverage with SCTG using modified supraperiosteal tunnel access technique. (F) 15 days after suture removal. (G) Three months postoperative/
initiation of orthodontic treatment (T1), showing keratinized tissue width. (H) At the middle of orthodontic treatment (T2). (I) At end of orthodontic leveling and 
alignment (Te). (J) Incisal view at end of orthodontic leveling and alignment (Te). 
SCTG: subepithelial connective tissue graft.
Root coverage in RT2 GR by perio-ortho treatment
https://doi.org/10.5051/jpis.2204100205
• Tooth with clinically detectable CEJ.
• Good patient compliance after phase I treatment (full mouth plaque score 90% accuracy (k value 0.84 and 0.81 respectively).
Root coverage in RT2 GR by perio-ortho treatment
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Root coverage in RT2 GR by perio-ortho treatment
https://doi.org/10.5051/jpis.2204100205
Randomization
Patients enrolled in the present study were randomized by generating a computerized 
list with block size of 4 and 6 using random allocation software system [29], by another 
investigator (NT). For allocation concealment, sequentially numbered sealed opaque 
envelopes were used. The outcome assessor (ST) was not blinded in this study. Patients were 
allocated into two groups with allocation ratio of 1:1 and the allotted treatmentwas informed 
to the operators (SM and RS) at T1 (prior to orthodontic treatment).
1) Mucogingival surgery and orthodontic treatment (test group): After completion of 
phase I therapy, root coverage procedure was done using SCTG. Three months following 
the graft placement, orthodontic treatment was initiated.
2) Mucogingival surgery alone (Control group): After completion of phase I therapy, root 
coverage was done using SCTG. Orthodontic treatment was deferred till the completion 
of this study in this group.
Intervention
Periodontal surgical procedure
Mucogingival surgery was performed by single operator (SM) in all the patients, who was not 
aware about the group allocation at the time of mucogingival surgery. Thorough scaling and 
root planing was performed using ultrasonic scaler (Woodpecker HW-3H scaler, Guangxi, 
China), hand scaler and curette (Hu-Friedy). After resolution of inflammation, mucogingival 
surgery was performed. Root prominence was reduced with the burs (Mani Dia Burs, New 
Delhi, India)/curette (Hu-Friedy). Root surface conditioning was not performed. Under local 
anaesthesia, recipient bed was prepared in the recession region using pouch and tunnel [30], 
or modified vestibular incision supraperiosteal tunnel technique (without frenectomy) [31], 
according to the clinical case indication. In pouch and tunnel technique, the recipient site 
was prepared by an internal beveled incision, using 15C blade (15 C Hu-Friedy) to eliminate 
the sulcular epithelium, followed by “envelope” preparation apically and laterally (3–5 mm) 
to the recession and extended beyond MGJ. Tunneling instruments (GDC, New Delhi, India), 
were used to prepare supraperiosteal tunnel/envelop. Care was taken to avoid detachment of 
the papillae. SCTG was procured from the palate using single incision technique proposed 
by Hürzeler et al. [32]. A number 15 scalpel blade (Surgeon Blades & Medical Devices Private 
Limited, Vadodara, India) was used to make a horizontal incision to the bone 2 mm away 
from the gingival margin of maxillary premolars. SCTG of approximately 2 mm in thickness 
and approximately three times wider than recession width (Figures 1D and 2C), was inserted 
into the prepared tunnel/envelop at recipient site (Figures 1E and 2D) and sutured using 
resorbable suture (5-0 Vicryl, Ethicon, Johnson & Johnson private limited, Mumbai, India).
Postoperative care
All the patients were advised not to use toothbrush and interdental aids for plaque control 
until the sutures had been removed. Cap. Amoxicillin (Almox, Alkem laboratories Ltd., 
Mumbai, India) 500 mg, 3 tabs per day for 5 days and Tab Brufen (Brufen, Abbott, Mumbai, 
India) 400 mg, 3 tablets per day for 3 days was prescribed to all patients. 0.2% chlorhexidine 
mouthwash (0.2% Hexidine, ICPA Health Products Ltd., Mumbai, India) twice daily was 
advised for 14 days. After10 to 14 days of surgery, sutures were removed. Patients were recalled 
for examination every 15 days (Figures 1F and 2E) for up to 1 month after surgery. Orthodontic 
treatment was initiated in test group patients after 3 months of SCTG (T1, Figure 1G) and 
clinical parameters were recorded at mid-orthodontic level (T2, Figure 1H) and at the end of 
leveling alignment of tooth having GR (approximately 8–9 months of initiation of orthodontic 
https://jpis.org 270
therapy, Te, Figure 1I and J). Control group patients were recalled after 3 months of SCTG 
(Figure 2F) and further followed up for 8–9 months (Te, Figure 2G and H).
Orthodontic procedure
Orthodontic treatment was carried out by the same orthodontist (RS) using fixed 
mechanotherapy. MBT 0.022 slot with wire sequencing 0.014 NiTi, 0.016 NiTi, 0.018 NiTi, 
0.018 SS, 0.017SS×0.025 SS was used, for leveling and alignment (Figure 1H-J). During 
orthodontic treatment, forces applied were light continuous and well-balanced. Home care 
oral hygiene maintenance program was reinforced in each patient and supragingival scaling 
was done, at each follow-up visit.
Statistical analysis
Data recorded were processed by standard statistical analysis using software (SPSS, version 
25, IBM, Armonk, NY, USA). Shapiro wilk test was applied to check normality. All clinical 
parameters except CAL, was found to be non-normally distributed. Friedman test and 
repeated measure analysis of variance (CAL) was applied to evaluate intragroup differences 
at different time points in both the groups, followed by Wilcoxon signed rank test and paired 
t-test respectively between any two time points. Intergroup comparison was done by Mann-
whitney U test and independent t-test. Pearson correlation was applied between RC%, mean 
iCAL. Spearman’s correlation was applied between RC% and GT. Point-biserial correlation was 
applied to find correlation of RC% with PP. The level of significance (P value) was set at 5%.
RESULTS
Thirty-six patients were recruited in the present study. Total six patients (3 in each group) 
were lost during follow up and thirty patients (15 in each group) completed treatment 
protocol. At three months of SCTG, one patient in test group did not report after state wide 
lockdown amid COVID-19. Three patients in control group were lost to follow-up due to 
non-compliant to follow-up visit. Two patients in test group turned COVID-19 positive at 
the middle of orthodontic treatment (Figure 3). Healing was uneventful after mucogingival 
surgery and no complications were observed throughout the treatment.
Table 1 demonstrates demographic data and clinical parameters. On applying Mann-whitney 
test, all the parameters were comparable at baseline.
Table 2 depicts intragroup comparison in test group at different time points. Comparison 
between T0 and T1, showed statistically significant reduction in PPD, gain in mCAL, gain 
in mean iCAL, reduction in REC, RW, increase in KTW, achieved RC%, increase in GT and 
improved RES (P≤0.05). Also, there was reduction in GI, PI, BOP and hypersensitivity, 
though it was non-significant (P>0.05). PP converted into thick phenotype in 9 out of the 13 
patients. Intragroup comparison between T1 and Te revealed statistically significant reduction 
in RW and gain in mean iCAL (P≤0.05). No deterioration was observed in REC, GT and 
KTW. The RC% achieved at 3 months (52.99%±39.59%) and at end of leveling alignment 
(66.67%±40.82%) have improved though it was non-significant (P>0.05).
Table 3 shows intragroup comparison in control group at different time points. Intragroup 
comparison between T0 and T1 revealed statistically significant improvement in mean PPD, 
Root coverage in RT2 GR by perio-ortho treatment
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Root coverage in RT2 GR by perio-ortho treatment
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mCAL, mean iCAL, mean GI and PI (P≤0.05). Statistically significant gain in KTW, achieved 
RC%, increase in GT, decreased REC and RW at the level of CEJ, improved hypersensitivity, 
and RES was also observed (P≤0.05). In 8 out of 14 patients, PP converted from thin to thick 
phenotype. Intragroup comparison of parameters between T0 and Te e revealed significant 
reduction in PPD, gain in mCAL and mean iCAL. REC reduced significantly, from mean score 
at T0 2.80±0.94 mm to 1.80±1.01 mm at Te. KTW and GT improved significantly. RC% was 
achieved (39.93%±31.41%).
Intergroup comparison of changes in parameters at T1 from baseline showed statistically non-
significant difference between the groups (P≤0.05) except mean iCAL (P>0.05). Changes in 
clinical parameters at Te from baseline (T0–Te) showed statistically significant improvement in 
achieved RC%, GT, RW at apical level (P≤0.05) in test group. There was significant increase in 
PI and mean GI and PPD in test group patients (P≤0.05). REC reduction and improvement in 
KTW was comparable (P>0.05) in test versus control group (Table 3).
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Excluded (n=32)
• Not meeting inclusion criteria
(n=14)
• Declined to participate (n=11)
• Other reasons (n=7)
Testgroup (n=18)
SCTG + orthodontic leveling and alignment
Received allocated intervention at baseline
Lost to follow-up at initiation of orthodontic treatment (n=1)
(state-wide lockdown amid COVID-19)
Lost to follow-up at mid-orthodontic treatment (n=2)
(turned COVID-19 positive)
Lost to follow-up at 3 months of SCTG (n=3)
(non-compliant to follow-up visit)
Lost to follow-up at 12 months (n=0)Lost to follow-up at end of leveling alignment (n=0)
Analyzed (n=15) Analyzed (n=15)
Control group (n=18)
SCTG only
Received allocated intervention at baseline
Enrollment
Allocation
Follow-up
Analysis
Assessment for eligibility (n=68)
Randomization (n=36)
SRP was performed in all the patients
Figure 3. Flow chart of study population. 
SRP: scaling and root planning, SCTG: subepithelial connective tissue graft, COVID-19: coronavirus disease 2019.
Correlation analysis demonstrated statistically significant negative correlation between RC% 
and mean iCAL (correlation coefficient r=−0.47, P=0.008). Correlation of RC% with GT and 
PP were also non-significant (r=0.07, P=0.719 and r=0.04, P=0.827, respectively).
DISCUSSION
The present randomized controlled trial was conducted to evaluate the root coverage 
achieved by interdisciplinary periodontal-orthodontic treatment in comparison to 
mucogingival surgical procedures alone. Miller class III/RT2 GR presents a challenge in 
achieving predictable coverage by mucogingival surgery due to associated parameters such 
as interdental bone loss and soft tissue loss. An interdisciplinary approach might be more 
favorable in achieving root coverage.
Mucogingival surgery was performed before orthodontic treatment in the present study to 
augment the GT and KTW. Moreover, the patients were concerned about their esthetics due 
to the presence of exposed root surfaces in anterior teeth. Wennström et al. [7] demonstrated 
gingival inflammation and the thickness of the marginal gingiva are crucial factors for the 
development of GR and attachment loss during orthodontic treatment. Mandibular incisors 
Root coverage in RT2 GR by perio-ortho treatment
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Table 1. Demographic table: clinical parameters of the study population in terms of mean±SD for continuous variables and frequency for categorical variables
Parameters Test group CI Control group CI P value
Upper bound lower bound Upper bound lower bound
Age 21.73±4.99 24.50 18.97 24.93±4.43 27.39 22.48 0.072
Sex (F:M) 10:5 - - 11:4 - - -
No. of surfaces involved
1 9 11
2 6 4
3 - -
GIa) 0.11±0.16 0.20 0.02 0.13±0.21 0.25 0.02 0.900
GIb) 0.00±0.00 0.00 0.00 0.00±0.00 0.00 0.00 1.000
PIa) 0.15±0.17 0.25 0.06 0.15±0.17 0.25 0.06 1.000
PIb) 0.20±0.41 0.43 −0.03 0.27±0.46 0.52 0.01 0.671
PPDa) (mm) 1.79±0.39 2.01 1.58 1.93±0.46 2.18 1.68 0.390
PPDb) (mm) 1.27±0.46 1.52 1.01 1.67±0.62 2.01 1.32 0.059
iCALa) (mm) 2.27±0.62 2.61 1.92 2.50±0.46 2.76 2.24 0.254
mCAL (mm) 3.50±1.15 4.14 2.86 4.27±1.10 4.88 3.66 0.072
BOPa) 0.02±0.09 0.07 −0.03 0.02±0.09 0.07 −0.03 1.000
BOPb) 0.00±0.00 0.00 0.00 0.00±0.00 0.00 0.00 1.000
RECb) (mm) 2.33±0.90 2.83 1.84 2.80±0.94 3.32 2.28 0.160
RWC (mm) 2.67±0.90 3.16 2.17 2.73±0.59 3.06 2.40 0.673
RWA (mm) 1.80±0.56 2.11 1.49 1.73±0.46 1.99 1.48 0.775
KTWb) (mm) 1.87±1.41 2.65 1.09 1.33±0.72 1.73 0.93 0.370
GT (mm) 0.60±0.21 0.72 0.49 0.66±0.19 0.77 0.56 0.183
HYS 0.93±1.22 1.61 0.26 1.20±1.37 1.96 0.44 0.562
Mild 6 7
Moderate 0 0
Severe 0 0
PP (thin:thick) 13:2 - - 14:1 - - -
MBL (mm) 2.76±0.42 2.99 2.52 2.89±0.33 3.07 2.70 0.204
DBL (mm) 2.86±0.48 3.12 2.59 2.93±0.61 3.27 2.60 0.902
Data are shown as mean ± standard deviation.
CI: confidence interval, F: female, M: male, GI: gingival index, PI: plaque index, PPD: probing pocket depth, iCAL: interdental clinical attachment level, mCAL: 
midlabial clinical attachment level, BOP: bleeding on probing, REC: recession depth, RWC: recession width at level of cementoenamel junction, RWA: recession 
width apically at the level of receded gingival margin, KTW: keratinised tissue width, GT: gingival thickness, HYS: hypersensitivity (reported by patients based on 
visual analogue scale), PP: periodontal phenotype, MBL: mesial alveolar bone loss, DBL: distal alveolar bone loss.
a)Mean; b)Mid labial.
Root coverage in RT2 GR by perio-ortho treatment
https://doi.org/10.5051/jpis.2204100205
included in this study usually present with thin labial bone and are more susceptible to 
developing or exhibiting worsening of existing GR during orthodontic treatment. Moreover, 
orthodontic brackets may lead to inflamed gingival margins and persistent inflammation, 
which in thin PP, may lead to GR [7]. So, the soft tissue augmentation before orthodontic 
treatment may prove to be more valuable in these cases.
In the current study, intergroup comparison of changes in parameters at T1 from baseline 
showed statistically non-significant difference between the groups that suggests no variations 
due to surgical techniques used and similar mean root coverage (RC% 52.99%±39.59% and 
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Table 2. Intragroup comparison of all clinical parameters at T0, T1, T2, and Te in test group
Parameters Baseline (T0) 3 months (T1) Upper 
bound 
CI
Lower 
bound 
CI
Mid-ortho (T2) Upper 
bound 
CI
Lower 
bound 
CI
End of L&A (Te) Upper 
Bound 
CI
Lower 
Bound 
CI
P value (Friedman test 
and repeated ANOVA 
[CAL])
GId) 0.11±0.16 0.07±0.14, 
P=0.157a)
0.14 −0.01 0.29±0.25 0.42 0.15 0.22±0.24, P=0.035b)f), 
P=0.132c)
0.35 0.09 0.004f)
GIe) 0.00±0.00 0.00±0.00, 
P=1.000a)
0.00 0.00 0.27±0.46 0.52 0.01 0.07±0.26, P=0.317b), 
P=0.317c)
0.21 −0.08 0.019f)
PId) 0.15±0.17 0.04±0.12, 
P=0.025a)f)
0.11 −0.02 0.35±0.20 0.46 0.24 0.31±0.15, P=0.001b)f), 
P=0.020c)f)
0.39 0.22 0.000f)
PIe) 0.20±0.41 0.00±0.00, 
P=0.083a)
0.00 0.00 0.67±0.49 0.94 0.40 0.47±0.52, P=0.008b)f), 
P=0.157c)f)
0.75 0.18 0.001f)
PPDd) (mm) 1.79±0.39 1.29±0.39, 
P=0.002a)f)
1.50 1.07 1.50±0.37 1.70 1.29 1.39±0.37, P=0.382b), 
P=0.010c)f)
1.59 1.18 0.003f)
PPDe) (mm) 1.27±0.46 1.00±0.38, 
P=0.046a)f)
1.21 0.79 1.33±0.49 1.60 1.06 1.27±0.46, P=0.046b)f), 
P=1.000c)
1.52 1.01 0.053f)
iCALd) (mm) 2.27±0.62 1.87±0.40, 
P=0.000a)f)
2.09 1.65 1.70±0.56 2.01 1.39 1.57±0.50, P=0.014b)f) 
P=0.000c)f)
1.84 1.29 0.000f)
mCAL (mm) 3.50±1.15 2.20±1.01, 
P=0.000a)f)
2.76 1.64 2.67±1.05 3.25 2.09 2.40±1.06, P=0.189b), 
P=0.003c)f)
2.98 1.82 0.000f)
BOPd) 0.02±0.09 0.00±0.00, 
P=0.317a)
0.00 0.00 0.09±0.15 0.17 0.00 0.11±0.16, P=0.025b)f), 
P=0.102c)
0.20 0.02 0.037f)
BOPe) 0.00±0.00 0.00±0.00, 
P=1.000a)
0.00 0.00 0.00±0.00 0.00 0.00 0.07±0.26, P=0.317b), 
P=0.317c)
0.21 −0.08 0.392
RECe) (mm) 2.33±0.90 1.20±1.08, 
P=0.002a)f)
1.80 0.60 1.27±1.16 1.91 0.62 0.93±1.16, P=0.102b), 
P=0.002c)f)
1.58 0.29 0.000f)
RWC (mm) 2.66±0.90 1.60±1.35, 
P=0.007a)f)
2.35 0.85 1.53±1.30 2.25 0.81 1.13±1.36, P=0.038b)f), 
P=0.002c)f)
1.88 0.38 0.000f)
RWA (mm) 1.80±0.56 1.20±1.01, 
P=0.024a)f)
1.76 0.64 1.07±0.96 1.60 0.53 0.67±0.90, P=0.023b)f), 
P=0.002c)f)
1.16 0.17 0.000f)
KTWe) (mm) 1.87±1.41 3.00±1.73, 
P=0.003a)f)
3.96 2.04 3.07±1.62 3.97 2.17 3.07±1.62, P=0.564b) 
P=0.003c)f)
3.97 2.17 0.000f)
GT (mm) 0.60±0.21 1.03±0.19, 
P=0.001a)f)
1.09 0.88 1.04±0.19 1.14 0.94 1.04±0.19, P=0.317b), 
P=0.001c)f)
1.14 0.94 0.000f)
HYS 0.93±1.22 0.27±0.70, 
P=0.063a)
0.66 −0.12 0.13±0.52 0.42 −0.15 0.13±0.52, P=0.317b), 
P=0.038cf)
0.42 −0.15 0.005f)
Mild 6 2 1
Moderate 0 0 0
Severe 0 0 0
RES - 7.13±2.13, 
P=0.001a)f)
8.31 5.95 7.13±2.33 8.42 5.85 7.73±2.60, P=0.180b), 
P=0.001c)f)
9.18 6.29 0.000f)
RC% - 52.99±39.59, 
P=0.002a)f)
74.92 31.07 51.67±40.61 74.15 29.18 66.67±40.82, P=0.061b), 
P=0.001c)f)
89.27 44.06 0.000f)
PP (thin:thick) 13:2 4:11 - - - - - 3:12 - - -
Data are shown as mean ± standard deviation.
T0: baseline, T1: 3 months of connective tissue graft/initiation of orthodontic treatment, T2: mid-orthodontic treatment, Te: end of leveling and alignment, 
CI: confidence interval, GI: gingival index,PI: plaque index, PPD: probing pocket depth, iCAL: interdental clinical attachment level, mCAL: midlabial clinical 
attachment level, BOP: bleeding on probing, REC: recession depth, RWC: recession width at level of cementoenamel junction, RWA: recession width apically at the 
level of receded gingival margin, KTW: keratinised tissue width, GT: gingival thickness, HYS: hypersensitivity (reported by patients based on visual analogue scale), 
RES: root coverage esthetics score, RC%: percentage root coverage, PP: periodontal phenotype, ANOVA: analysis of variance, CAL: clinical attachment level.
a)Intragroup comparison between T0 and T1; b)Intragroup comparison between T1 and Te; c)Intragroup comparison between T0 and Te; d)Mean; e)Mid labial; f)P value 
≤0.05 indicates significance.
33.33%±27.28% in the test and control group respectively) was achieved by connective tissue 
graft after 3 months of SCTG placement in both groups. Both techniques offer minimally 
invasive approach for the treatment of recession defects and preserve papillae integrity, 
adequate blood supply to the underlying graft, and esthetics [30,31]. Therefore, minimally 
invasive approach was chosen in the present study over the CAF. A recent RCT also reported 
no significant difference in mean root coverage achieved at 6 and 12 months follow-up in 
Root coverage in RT2 GR by perio-ortho treatment
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Table 3. Intragroup comparison of all clinical parameters in control group and Intergroup comparison of changes (T0−T1 and T0−Te) in all clinical parameters
Parameters Baseline 
(T0)
3 months 
(T1)
Upper 
bound 
CI
Lower 
bound 
CI
Control group 
(T0−T1)
Test group 
(T0−T1)
12 months 
(Te)
Upper 
bound 
CI
Lower 
bound 
CI
Control group 
(T0−Te)
Test group 
(T0−Te)
P value 
(Friedman test 
and repeated 
measure 
ANOVA [CAL])
GIf) 0.13±0.21 0.02±0.09, 
P=0.025a)e)
0.07 0.03 0.11±0.16 0.04±0.12, 
P=0.203c)
0.00±0.00, 
P=0.034b)e)
0.00 0.00 0.13±0.21 −0.11±0.27, 
P=0.013d)e)
0.009e)
GIg) 0.00±0.00 0.00±0.00, 
P=1.000a)
0.00 0.00 0.00±0.00 0.00±0.00, 
P=1.000c)
0.00±0.00, 
P=1.000b)
0.00 0.00 0.00±0.00 −0.07±0.26, 
P=0.317d)
-
PIf) 0.15±0.17 0.07±0.14, 
P=0.046a)e)
0.14 −0.01 0.09±0.15 0.11±0.16, 
P=0.695c)
0.09±0.15, 
P=0.083b)
0.17 0.00 0.07±0.14 −0.15±0.21, 
P=0.003d)e)
0.039e)
PIg) 0.27±0.46 0.00±0.00, 
P=0.046a)e)
0.00 0.00 0.27±0.46 0.20±0.41, 
P=0.671c)
0.00±0.00, 
P=0.046b)e)
0.00 0.00 0.27±0.46 −0.27±0.70, 
P=0.023d)e)
0.018e)
PPDf) (mm) 1.93±0.46 1.42±0.43, 
P=0.002a)e)
1.66 1.18 0.51±0.41 0.51±0.35, 
P=0.849c)
1.38±0.43, 
P=0.002b)e)
1.62 1.14 0.55±0.43 0.41±0.49, 
P=0.376d)
0.000e)
PPDg) (mm) 1.67±0.62 1.20±0.41, 
P=0.008a)e)
1.43 0.97 0.47±0.52 0.27±0.46, 
P=0.264c)
1.20±0.41, 
P=0.008b)e)
1.43 0.97 0.47±0.52 0.00±0.53, 
P=0.026d)e)
0.001e)
iCALf) (mm) 2.50±0.46 1.80±0.56, 
P=0.000a)e)
2.11 1.49 0.70±0.25 0.40±0.34, 
P=0.010c)e)
1.63±0.52, 
P=0.000b)e)
1.92 1.35 0.87±0.35 0.70±0.65, 
P=0.389d)
0.000e)
mCAL (mm) 4.27±1.10 3.000±1.000, 
P=0.00a)e)
3.55 2.45 1.27±0.88 1.30±0.96, 
P=0.922c)
2.87±1.19, 
P=0.000b)e)
3.52 2.21 1.40±0.99 1.10±1.17, 
P=0.453d)
0.000e)
BOPf) 0.02±0.09 0.000±0.000, 
P=0.317a)
0.00 0.00 0.02±0.09 0.02±0.09, 
P=1.000c)
0.00±0.00, 
P=0.317b)
0.00 0.00 0.02±0.09 −0.09±0.20, 
P=0.049d)e)
0.368
BOPg) 0.00±0.00 0.000±0.000, 
P=1.00a)
0.00 0.00 0.00±0.00 0.00±0.00, 
P=1.000c)
0.00±0.00, 
P=1.000b)
0.00 0.00 0.00±0.00 −0.07±0.26, 
P=0.317d)
-
RECg) (mm) 2.80±0.94 1.866±0.833, 
P=0.001a)e)
2.33 1.40 0.93±0.59 1.13±0.74, 
P=0.403c)
1.80±1.01, 
P=0.001b)e)
2.36 1.24 1.00±0.65 1.40±0.91, 
P=0.162d)
0.000e)
RWC (mm) 2.73±0.59 2.07±0.80, 
P=0.008a)e)
2.51 1.62 0.67±0.72 1.07±1.10, 
P=0.364c)
1.87±0.92, 
P=0.004b)e)
2.37 1.36 0.87±0.74 1.53±1.13, 
P=0.098d)
0.000e)
RWA (mm) 1.73±0.46 1.60±0.74, 
P=0.317a)
2.01 1.19 0.13±0.52 0.60±0.83, 
P=0.117c)
1.47±0.83, 
P=0.102b)
1.93 1.00 0.27±0.59 1.13±0.74, 
P=0.003d)e)
0.135
KTWg) (mm) 1.33±0.72 2.60±0.91, 
P=0.001a)e)
3.10 2.10 −1.27±0.59 −1.13±0.83, 
P=0.718c)
2.60±0.91, 
P=0.001b)e)
3.10 2.10 −1.27±0.59 −1.20±0.94, 
P=0.805d)
0.000e)
GT (mm) 0.66±0.19 0.99±0.19, 
P=0.001a)e)
1.09 0.88 −0.32±0.14 −0.42±0.17, 
P=0.074c)
0.99±0.19, 
P=0.001b)e)
1.09 0.88 −0.32±0.14 −0.43±0.16, 
P=0.038d)e)
0.000e)
HYS 1.20±1.14 0.13±0.52, 
P=0.023a)e)
0.42 −0.15 1.07±1.39 0.67±1.18, 
P=0.397c)
0.13±0.52, 
P=0.023b)e)
0.42 −0.15 1.07±1.39 0.80±1.21, 
P=0.578d)
0.002e)
Mild 7 1 1
Moderate 0 0 0
Severe 0 0 0
RC% - 33.33±27.28, 
P=0.001a)e)
48.43 18.22 −33.33±27.28 −52.99±39.59, 
P=0.189c)
39.93±31.41, 
P=0.002b)e)
56.83 22.04 −39.93±31.41 −66.67±40.82, 
P=0.049d)e)
0.000e)
RES - 6.20±1.70, 
P=0.003a)e)
7.14 5.26 −6.20±1.70 −7.13±2.13, 
P=0.227c)
6.60±1.84, 
P=0.001b)e)
7.62 5.58 −6.60±1.84 −7.73±2.60, 
P=0.171d)
0.000e)
PP 
(thin:thick)
14:1 6:9 - - - - 6:9 - - - - -
Data are shown as mean ± standard deviation.
T0: baseline, T1: 3 months of connective tissue graft/initiation of orthodontic treatment, T2: mid-orthodontic treatment, Te (Control group): 12 months of 
connective tissue graft, Te (Test group): end of leveling and alignment, CI: confidence interval, mn-mean, ML-mid labial, GI: gingival index, PI: plaque index, PPD: 
probing pocket depth, iCAL: interdental clinical attachment level, mCAL: midlabial clinical attachment level, BOP: bleeding on probing, REC: recession depth, 
RWC: recession width at level of cementoenamel junction, RWA: recession width apically at the level of receded gingival margin, KTW: keratinised tissue width, 
GT: gingival thickness, HYS: hypersensitivity (reported by patients based on visual analogue scale), RC%: percentage root coverage, RES: root coverage esthetics 
score, PP: periodontal phenotype, ANOVA: analysis of variance, CAL: clinical attachment level.
a)Intragroup comparison between T0 and T1 in control group; b)Intragroup comparison between T0 and Te in control group; c)Intergroup comparison of changes 
in clinical parameters at T0 and T1 (T0−T1); d)Intergroup comparison of changes in clinical parameters at T0 and Te (T0−Te); e)P value ≤0.05 indicates significance; f)
Mean; g)Mid labial.
Root coverage in RT2 GR by perio-ortho treatment
https://doi.org/10.5051/jpis.2204100205
Miller’s class III/RT2 GR treated with SCTG using tunneling technique compared to CAF [33]. 
CRC was obtained in 5 cases of test group and only in 1 case of control group after 3months 
of SCTG placement. Outcome may be less predictable in presence of thin gingival phenotype, 
shallow vestibule, and high frenal attachment and/or muscle pull in mandibular anterior 
region. Factors like loss of papillary height, tooth malposition, dimension of GR, number of 
root surfaces involved may also limit the level of recession coverage in such cases.
In the present study, an intergroup comparison of changes at the end of the study from the 
baseline (T0-Te) showed significant improvement in RC%, GT, and RW at the apical level. 
The findings showed an improvement in RC% of approximately 27% in the test group at the 
end of leveling and alignment. The difference in REC reduction seen in the test group as 
compared to the control group was nearly 0.5 mm which though statistically non-significant, 
has clinical relevance. CRC was achieved in 8 cases (53.3% of cases) in the test group versus 
only 2 cases (13.3%) in the control group. Similar findings were reported in an RCT with CRC 
in 43.75% of cases and mean RC% of 69.32%±30.74% at the end of leveling alignment, where 
SCTG was performed before orthodontic treatment [21].
In the test group, orthodontic treatment was initiated after 3 months of the mucogingival 
procedure once wound healing was accomplished [21,34]. Intragroup comparison at T1 
and Te in the test group revealed that RC% at the end of leveling and alignment improved 
further as compared to that obtained 3 months after SCTG. This improvement of 14% though 
statistically non-significant, is of clinical significance,implying that orthodontic treatment 
led to further coronal advancement of the gingival margin. Wennström et al. [35] suggested 
that when a facially positioned tooth is moved within the alveolar process, the GT increases 
on the facial aspect which leads to increased free gingival height and decreased clinical crown 
height. Similarly, the reduction in RW was also maintained at the end of leveling alignment 
in this study. An RCT conducted by Mehta et al. [21], showed similar findings in their test 
group. Recession coverage achieved in their study was comparable at the end of leveling and 
alignment with the present study, despite of inclusion of malaligned teeth having Miller class 
III GR with interdental clinical attachment loss in this study.
Intragroup comparison of parameters between T0 and Te in control group revealed RC% 
achieved was 39.93%±31.41%. In agreement with this finding, an RCT showed mean RC% of 
56.49% in Miller class III/RT2 GR using m-VISTA along with SCTG after 12 months of follow-
up [33]. Another case series reported mean root coverage of 58.72% after 6 months of follow 
up, treated with m-VISTA and SCTG, having multiple mandibular GRs including posterior 
teeth as well [36]. The results achieved in the present study in terms of RC% imply that root 
coverage with SCTG can be attempted in patients with malaligned teeth in the presence of 
interdental bone and soft tissue loss, who are not willing to undergo orthodontic treatment 
due to any reason.
Interdental CAL may indirectly indicate the changes in underlying bone level and it has been 
proven to be an important prognostic factor in consideration of success of root coverage 
procedure in Miller class III/RT2 GR [17,37]. There was statistically significant gain in mean 
iCAL in test and control groups, three months after SCTG placement, and these results were 
maintained till the end of the study. Correlation analysis revealed statistically significant 
negative correlation between RC% and baseline mean iCAL (P=0.008) in this study. A similar 
correlation was found between these two factors in a study by Cairo et al. [17].
https://jpis.org 276
In the present study, statistically significant improvement in KTW and GT was observed 
after 3 months of SCTG placement, in both groups. Regarding the correlation of RC% with 
PP and GT, no correlation was found between these parameters in the present study and this 
finding was also supported by Jepsen et al. [38]. However, improved PP might have helped in 
maintaining the stable gingival margin level till the end of the follow-up in this study. Mehta 
et al. [21], reported gingival margin stability throughout orthodontic treatment, in cases 
where SCTG was placed prior to orthodontic treatment.
Patient-centered outcomes in terms of hypersensitivity and esthetic score at Te showed 
statistically significant improvement when compared to T0, in both groups. In the test group, 
mean VAS score for hypersensitivity was 0.93±1.22 at baseline which reduced significantly 
to 0.13±0.52 at the end of follow-up. Out of six patients who had chief complaints of 
hypersensitivity, five patients had complete relief at the end of leveling alignment. A 
statistically significant reduction in hypersensitivity mean score at the end of leveling 
alignment was also observed in another study [21]. In the control group, six out of seven 
patients got complete relief from hypersensitivity after SCTG placement. The mean VAS score 
reduced statistically significantly from 1.20±1.14 at baseline to 0.13±0.52 at the end of follow-
up. An RCT conducted by Cairo et al. [17] also showed similar findings.
In this study, mean RES scores observed at the end of follow-up was 7.73±2.60 and 6.60±1.84 
in the test and control group respectively. A study reported, SCTG and orthodontic leveling 
alignment led to RES mean scores of 8.00±1.79 [21]. Another study revealed RES mean score of 
7.6±1.7 at 6 months follow-up, in cases where CAF and SCTG were performed [17]. An ideal RES 
score of 10 was observed in 7 cases of test group while only in 2 cases of control group at Te.
In the present study, an extruded tooth was excluded because orthodontic intrusion may 
give misleading results of recession coverage. Tooth having TFO was also excluded as TFO 
would disturb wound healing and may affect the surgical outcome. Root conditioning was 
not performed as literature reported no added advantage of root conditioning on the clinical 
outcomes of root coverage in GR using SCTG [39]. However, the study has the following 
limitations. Patients who received orthodontic treatment could be followed only till the 
end of leveling and alignment due to time constraints, and to have a uniform endpoint. 
Standardization of cases could not be done in terms of number of root surfaces involved. Less 
number of patients could complete the treatment protocol due to COVID-19. Cone-beam 
computed tomography was not used to assess the alveolar bone status.
Within the limitations of the present study, it can be concluded that mucogingival surgery 
followed by orthodontic treatment may result in more root coverage in malaligned 
mandibular anteriors having isolated Miller class III/RT2 GR as compared to mucogingival 
surgery alone. Satisfactory improvement was observed in hypersensitivity and esthetics 
on completion of orthodontic leveling and alignment. Further, multicentered research 
with greater sample size, different tooth types, and comparison among arches, using an 
alternative to SCTG, is required as variations in these factors may influence the results.
ACKNOWLEDGEMENTS
The authors acknowledge the “Post Graduate Institute of Dental Sciences, Rohtak” for 
providing all the facilities to conduct this study.
Root coverage in RT2 GR by perio-ortho treatment
https://doi.org/10.5051/jpis.2204100205https://jpis.org 277
Root coverage in RT2 GR by perio-ortho treatment
https://doi.org/10.5051/jpis.2204100205
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Root coverage in RT2 GR by perio-ortho treatment
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https://doi.org/10.1111/jre.12296
	Clinical evaluation of root coverage in Miller class III/RT2 labial gingival recession treated with interdisciplinary periodontal-orthodontic therapy: 
a randomized controlled clinical trial
	INTRODUCTION
	MATERIALS AND METHODS
	Sample size
	Clinical parameters
	Data collection method
	Intraexaminer reproducibility
	Randomization
	Intervention
	Periodontal surgical procedure
	Postoperative care
	Orthodontic procedure
	Statistical analysis
	RESULTS
	DISCUSSION
	REFERENCES