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.

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
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55. 55