When Not to Perform Root Coverage Procedures

1048 It is challenging to discuss contraindications for root coverage procedures, since the line between indications and contraindications is not clearly delineated. Periodontal plastic surgery is an art as much as a science, and a skilled practitioner can obtain more satisfactory results than those with less skill and experience. The reality is that there are more relative contraindications than absolute contraindications for root coverage procedures. The purpose of this paper is to review the risk factors and other considerations that may influence a clinician’s decision not to perform a root coverage procedure. For the sake of brevity, this discussion is limited to patients who are in good health. The management of medically compromised patients is not germane to this discussion. Before treating any periodontal condition, including recession, one must first identify the risk factors responsible for that condition. Risk factors can be subdivided into those that can be modified or corrected, and those that cannot. Risk factors that cannot be modified or corrected may be considered to be contraindications for root coverage procedures. One risk factor that usually cannot be modified is the loss of interproximal bone. Miller1 published a classification of gingival recession that took this factor into account. Class III defects are those with generalized interproximal and radicular bone loss, or a supra-erupted tooth in which the relationship of the cemento-enamel junction to the alveolar crest mimics interproximal bone loss. Class IV defects have severe destruction of the interproximal bone between 2 teeth, such as that seen in cases of necrotizing ulcerative periodontitis. Miller stated that root coverage in Class III and IV defects could not be accomplished. Although there have been case reports in which sites with interproximal bone loss have been treated with some success,2 there are no randomized controlled studies of these procedures. In the event that this proves to be a predictable procedure, the prognosis for Class III and IV recession may also improve. Other authors have published cases where soft tissue coverage of Class IV defects and regeneration of interdental papillae have been possible.3,4 Nevertheless, at this time, Class III and Class IV defects are poor candidates for treatment.