CLINICAL TECHNIQUE REVIEW

TISSUE RECESSION

Miller Classification of Marginal Tissue

Recession Revisited After 35 Years
P.D. Miller, DDS

Abstract: Published more than three decades ago, the original classification of marginal tissue recession
described four classes of recession. For example, in Miller Class III recession, there were different scenarios
in which complete root coverage could not be achieved. Today, however, newer surgical techniques have made
it possible for clinicians to potentially achieve complete root coverage when interdental bone loss exists.
Currently, dentistry has a better understanding of the role of interdental papilla. Therefore, this article pres­
ents a new classification of papilla form that emphasizes the significance of the width and height of the papilla.
Additionally, an updated classification of periodontal terminology will be presented.

he original article on classification of marginal tis­ However, in the original article, the distinction between attached

T
sue recession, published m ore than 30 years ago, and unattached gingiva was not emphasized. Miller Class III reces­
described four classes of recession.1The com mon sion pointed out two scenarios in which complete root coverage
feature of M iller Class I and Class II recession was could not be achieved. One was an extruded tooth with no interdental
no loss of interdental bone or soft tissue, and com ­ bone or soft-tissue loss and the other was associated with loss of
some interdental bone and soft tissue th at limited the am ount of
plete root coverage could be predictably achieved. The difference
between a Class I and Class II recession was based on w hether or root coverage that could be achieved. Newer surgical techniques
not the recession extended to or beyond the mucogingival ju n c­ now allow the clinician to sometimes attain complete root coverage
tion (MGJ). when interdental bone loss exists. In Miller Class IV recession, the

Fig 1. Class I recession. Note that the free gingival groove separates the unattached gingiva from the attached gingiva. Fig 2. Class II recession.
Although there may be gingiva on the facial, if it is unattached the recession is Class II. The only way to accurately determine this is to probe and
see if the probe goes beyond the MGJ.

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C L I N I C A L T E C H N IQ U E R E V I E W ! TISSUE RE CESSION

interdental recession was described as being severe and the papilla
absent, which meant that root coverage was unachievable.
Currently, dentistry also has a more complete understanding of
the role of interdental papilla. This article presents a new classifi­
cation of papilla form that points out the significance of the width
and height of the papilla. Also, because there is some confusing
periodontal terminology that warrants a revisit, a new classifica­
tion of these term s—intended to be an updated, more accurate
description of the terminology—will be presented (Table 1). The
author will use these terms throughout the article.
A Brief Look Back
W hen the original classification of marginal tissue recession
was published, the emphasis in periodontics was on the treat­
ment of disease and not esthetics.1Non-disease surgery was re­
ferred to as mucogingival surgery.- The concept of periodontal

TABLE 1

Updated Description of Periodontal Plastic Surgery Terms and Procedures

| Current Term Proposed Term Rationale for Update

M u coging ival s urgery or P eriod onta l p lastic surgery The tw o c u rre n t term s have been a n tiq u a te d fo r
so ft-tis s u e surgery m ore tha n 3 0 years.

Free g in g iv a l g ra ft (FGG) E pithe lia lize d palatal g ra ft (EPG) "F ree” is n o t a s c ie n tific term .

C oro nally advanced flap C oro nally p o s itio n e d fla p (CPF) “A dvan ce” means to m ove fo rw a rd . In this
procedu re, th e fla p is p o s itio n e d coronally.

Pedicle g ra ft (fla p ) o r lateral sliding flap La tera lly p o s itio n e d fla p (LPF) This is in reference to a fla p and n o t a g ra ft, and
th e fla p is p o s itio n e d laterally.

A p ic a lly re p o s itio n e d fla p A p ic a lly p o s itio n e d fla p (A P F) "R e p o s itio n ” means to replace o r p u t back.
This fla p is a p ica lly p o sitio ned .

C row n le n g th e n in g surgery C row n exposure su rgery (CES) In this procedure, the crown is not actually
lengthened, rather the anatomical crown is exposed.

G um m y sm ile Excessive g in g iva l displa y The c u rre n t te rm is an info rm al one, w hereas

th e p ro p o se d te rm is a professional term .

A lte re d passive e ru p tio n Incomplete exposure o f the anatom ic crown The c u rre n t te rm is con fusing, w hereas the
p ropose d te rm is a m ore d e s c rip tiv e te rm th a t
is easily un derstood .

B io lo g ic w id th B io lo g ic h e ig h t W id th is a lateral an atom ica l dim ension,

w hereas th is te rm is re fe rrin g to a ve rtical
an atom ica l dim ension.

(n o n e ) O b liq u e ly p o s itio n e d fla p This is a va ria tio n o f th e c o ro n a lly p o sitio n e d

flap, w h ich is site spe cific. This te rm is used on
m a xilla ry cen tral incisors so as n o t to co ro n a lly
p o s itio n th e frenum .

Frene ctom y Frenal surgery O ften in th e m andibular arch w here the recession
extends to the frenum , g rafting can be done to
restore attached gingiva coronal to the frenum ,
and significa nt ro o t coverage can be gained.

TABLE 2

Types of Interdental Papilla

1 Type A Type B TypeC

There is no inte rden tal bone loss. There is no inte rden tal bone loss. There is inte rden tal bone loss, o r th e to o th
is extruded.

The papilla extends 5 m m coronal to The papilla extends 5 m m coronal to the If there is inte rden tal bone loss, the papilla
th e inte rden tal bone crest. inte rden tal bone crest. m ay o r m ay n o t fill th e inte rden tal space.

The papilla is s3 m m w ide a t its base The papilla is a3 m m w ide at its base at The papilla may be s3 m m w id e a t its base at
at the level o f a d ja cent CEJs. the level o f a d ja cent CEJs. th e level o f a d ja cent CEJs.

C om p lete ro o t coverage is expected. The p re d ic ta b ility o f co m p le te ro ot C om p lete ro o t coverage is n o t exp ected b u t

coverage is com prom ised. m ay be achieved u n der certain circum stances.

516 COMPENDIUM September 2018 Volume 39, Number 8

plastic surgery had ju st been introduced and periodontics was
entering a new era.:1
The focus of mucogingival surgery was to produce a functional
result, while the em phasis of periodontal plastic surgery was to
achieve not only a functional result but an esthetic one as well. At
that time, the options for treating marginal tissue recession were
limited and included the laterally positioned flap (LPF), coronally
positioned Hap (CPF), and epithelialized palatal graft (EPG).4'6
While both the LPF and CPF produced a very pleasing esthetic
result, the EPG had major drawbacks. Not only did it require a
second surgical wound, but also the color variation was apparent
and it often resulted in tissue with a keloid appearance.
A significant breakthrough came with the presentation of the
subepithelial connective tissue graft (SCTG).741 In this technique,
the graft was covered by an overlying flap providing bilam inar cir­
culation and additional blood supply that enhanced graft survival.9
The graft was harvested from within the palate, reducing palatal
discom fort. Currently, allograft and xenograft m aterials are b e­
ing substituted for the patient’s tissue, thus avoiding the palatal
wound. The status of allograft and xenograft materials is outlined
in the report from the 2014 American Academy of Periodontology
Regeneration Workshop.10
W ith current advances havingbeen made in surgical techniques,
there is a need to revisit M iller’s original classification. A new clas­
sification of the papilla is added.
www.Gompendiumlive.com
Class I and Class II Recession
In Class I and Class II recession, there is no loss of interdental bone
or soft tissue, and complete root coverage is expected. The difference
between these two classes is the presence or absence of attached gin­
giva (Figure 1). Class I recession was originally described as recession
that does not extend to the MGJ. While this is true, the distinction
between attached and unattached gingiva was not emphasized. If
gingiva was present on the facial, it was considered a Class I recession.
In reality, if the gingiva is unattached, there is “hidden recession,”
and this is actually a Class II recession (Figure 2).11Therefore, in
sites where gingiva is present on the facial, it is necessary to probe
to determine whether the gingiva is attached or unattached.
While complete root coverage is attainable in both Class I and Class
11 recession, different treatm ent modalities m aybe indicated. For
example, if adequate keratinized tissue is present in a Class I recession,
the simplest root coverage procedure, CPF, maybe indicated, whereas
in a Class II recession some type of soft-tissue grafting would be re­
quired. The CPF often can be done in a Class I recession but not in a
Class II. Treatment of a Class II recession requires more complicated
grafting procedures. Combining Class I and Class 11 into a single clas­
sification could be detrimental to the understanding of the clinician
attempting root coverage. In the author’s view, a new classification of
recession presented at the 2017 World Workshop on the Classification
of Periodontal and Peri-Implant Diseases and Conditions12that com­
bines Class I and Class 11 did not take this into consideration.
Fig 3 and Fig 4. Class III reces­
sion (Fig 3) was originally
described as interdental loss of
bone and/or soft tissue or ex­
trusion of the tooth. Only partial
root coverage could be attained.
Using the tunneling technique,
by undermining and elevating
the papilla, further root coverage
can be gained in certain Class
III recessions (Fig 4). Fig 5. In
Class IV recession, regardless of
severity of recession, root cover­
age cannot be achieved because
there is no papilla.
September 2018 COMPENDIUM 517
C LIN IC AL TECHNIQUE R EVIEW | TISSUE RECESSION

Fig 6. Class II recession with

type A papillae. The papil­
lae are a3 mm. Fig 7. Class II
recession with a type B papilla
between the central incisors.
The papilla is <3 mm. Fig 8. The
papilla between teeth Nos. 24
and 25 is type A. The papilla
between teeth Nos. 22 and 23
iistype C. Note the interdental
recession on the distal of No. 23
and the mesial of No. 22.

Class III Recession the advent of the tunneling technique, the volume of the papilla
Class III recession was originally described as interdental loss takes on greater significance, particularly regarding the mesial-
of bone and/or soft tissue or extrusion of the tooth. Only partial distal width of the papilla at the line angle of adjacent teeth. A
root coverage could be attained. By undermining and elevating the papilla with adequate size within the facial-lingual area provides
papilla using the tunneling technique/3'15further root coverage can a greater blood supply for the graft. This contributes to improved
be gained in certain Class III recessions (Figure 3 and Figure 4). proximal root coverage in Miller Class III sites.
When the original classification article was written, the empha­
sis of periodontal treatment was on health and function rather than Papilla Classification
esthetics. The images in the original article showed only Class III Based on the author’s observations and as he has previously pre­
recessions with no attached or unattached gingiva. Often the root sented on various occasions, papillae can be divided into three
exposure was an esthetic problem rather than a functional one, types: A, B, and C (Table 2). Type A and type B are similar in that
and attempting even partial root coverage was not considered. there is no interdental bone loss. The papilla extends 5 mm coro-
nally to the crest of the interdental bone.
Class IV Recession The difference between the two is the width of the papilla. A type
In Class IV recession, regardless of severity of recession, root cov­ Apapilla is a3m m wide at its base (Figure 6) and a type B papilla is
erage cannot be achieved because there is no papilla (Figure 5). <3 mm wide (Figure 7). In type C papilla, there is either interdental
bone loss or the tooth is extruded (Figure 8). Whenever there is
Significance of Interdental Papilla in Root interdental bone loss, the papilla is always a type C.
Coverage Grafting Where there is interdental bone loss, the papilla may extend
In 1992, Tarnow et al showed that the height of a normal interden­ >5 mm coronal to the crest of interdental bone. Determining a
tal papilla was 5 mm coronal to the crest of the bone interdentally.16 type C papilla can be challenging because the papilla form may not
In 1998, Nordland and Tarnow published a classification of papilla necessarily follow the bone form. Because there is bone loss in tire
recession as it relates to the cementoenamel junction (CEJ).17 interdental area and the papilla has not receded, the recognized
However, it is a 1-dimensional description that does not take into 5 mm dimension may be greater and there is hidden recession in
account the width or facial- lingual dimension of the papilla. With the interdental area. The distinguishing feature is that there is loss

518 COMPENDIUM September 2018 Volume 39, Number 8

CLINICAL TECHNIQUE REVIEW | TISSUE RECESSION
of interdental bone. The width of a type C papilla may be <3 mm.
Clearly, a wider papilla is more desirable.
Class I and Class 11recessions have either a type Aor type B papilla.
A Class III recession has a type C papilla, and a Class IV recession
has no papilla. Type A papillae provide a favorable environment for
graft survival, while type B papillae provide a more limited source of
blood supply and stability as their width narrows, thereby reducing
predictability of complete root coverage.
In the maxillary anterior, unless teeth are malaligned, the width
of a type A papilla is t>3 mm. Conversely, in the mandibular arch
the papilla is seldom this wide, especially when the mandibular
anterior teeth are crowded. The papilla width, height, and distance
from the bone crest impact the amount of root coverage that can be
achieved in Class 111 recession sites. Clinical experience shows that
adequate papilla width is necessary for providing sufficient blood
supply and tissue volume for placing a suture.
Conclusion
With the advent of the tunneling technique and subsequent modi­
fications allowing coronal positioning of the tunnel and elevation
of the papillae, complete root coverage of mild Class III recessions
has become possible.13,18'20The papilla form becomes an important
factor in such sites. In addition to the features of a type C papilla
described above, the papilla needs to have sufficient volume facial-
lingually to survive the coronal movement. In an ideal setting, up
to 2 mm of vertical papilla gain may be achieved. The advantages
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of the tunneling technique include complete coverage of the graft,
the undermining and elevation of the interdental papilla, and the
avoidance of external vertical or horizontal incisions.
ABOUT THE AUTHOR
PAX M ille r , D O S
Clinical Professor, Medical University o f South Carolina, Charleston, South Carolina;
Fellow, International Society o f Periodontal Plastic Surgeons
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