Aesthetic perception after root coverage procedure

The mucosal released-coronally advanced flap: A novel surgical approach-A case report

BACKGROUND

The coronally advanced flap (CAF) can be a predictable surgical technique for the treatment of gingival recessions. However, the characteristics of the defect (e.g., limited amount of keratinized gingiva or flap tension, etc.) may limit the use of the CAF with a possible requirement of additional surgical interventions (i.e., the use of a tissue graft to be harvested from donor sites or connective tissue substitutes).

METHODS

A 28-year-old woman patient, with no history of periodontal disease, came for referral presenting receding gums as a chief complaint, poor esthetics, and dentinal hypersensitivity at the buccal surface of teeth 11, 12, and 13. Clinically, she presented a thick phenotype with gingival recession type, RT1, with detectable cemento-enamel junction (A‒) in the second quadrant. To reduce the need of harvesting soft tissue grafts, the amount of cutting of muscles and vessels from the inner portion of the flap and mitigate the postoperative discomfort associated with the CAF, a novel surgical approach is described here using an advanced flap that incorporates an external incision along the mucogingival junction.

RESULTS

The average root coverage achieved with the novel procedure presented in this case report was 95%, along with an increased amount of keratinized gingiva and minimal postoperative patient's discomfort.

CONCLUSIONS

The mucosal released CAF is a promising technique in which the CAF technique alone may not be an indication.

KEY POINTS

This technique has the following advantages: Reduce the need of harvesting soft tissue grafts. Reduce the amount of cutting of muscles and vessels from the inner portion of the flap. Minimal postoperative discomfort for the patient.

Analysis of the treatment of RT2 recessions with a xenogeneic collagen matrix vs. connective tissue graft combined with a coronally advanced flap. A double-blinded randomized clinical trial

OBJECTIVES

To compare the clinical efficacy in terms of mean root coverage in RT2 recession treated with a coronally advanced flap combined with a xenogeneic collagen matrix versus a connective tissue graft.

MATERIALS AND METHODS

A total of 20 patients were randomized to receive one of two treatments: coronally advanced flap + xenogeneic collagen matrix (test group) and coronally advanced flap + connective tissue graft (control group). Patient-related outcomes measures and professional aesthetic assessment by root esthetic score were performed. A descriptive and analytical statistical analysis of the variables was performed.

RESULTS

At 12 months, the mean root coverage was 56.48% in the test group and 69.72% in the control group (p = 0.048), with a 35% and 40% complete root coverage in the xenogeneic collagen matrix and connective tissue graft, respectively. Test group presented less pain (3.65 vs. 5.2 VAS units) (p = 0.015) and less surgical time (45 vs. 49.15 min) (p = 0.004) than control group.

CONCLUSION

The use of xenogeneic collagen matrix in RT2 recessions was effective for recession reduction to those obtained using autologous grafts; with the advantage that the duration of surgery and patient morbidity decreased. Therefore, xenogeneic collagen matrix in RT2 recessions could be an alternative to autologous grafts.

CLINICAL RELEVANCE

The use of xenogeneic collagen matrix decreases the surgery time and patient morbidity but connective tissue graft results in significantly better mean root coverage and complete root coverage. Xenogeneic collagen matrix can be used in the treatment of RT2 gingival recessions.

STUDY REGISTRATION

NCT03344315.

Challenges and success in periodontal plastic surgery

To truly understand a field of study, one must delve into its past and examine the challenges and successes that have shaped its current practices. In the case of periodontal plastic surgery, recognizing how challenges induced changes over the last 70 years-from the 1950s to today-is essential to fully comprehend its evolution. This editorial provides a perspective on the field, highlighting the interrelationships between influential surgical techniques and advancements in research methodology. With each event building upon the last, the evolution of periodontal plastic surgery is a story of scientific progress and ongoing research, fostering a sense of community and shared knowledge.

Patient and professional use of the root coverage esthetic score (RES) and how it relates to patient satisfaction following periodontal plastic surgery

Background

Following periodontal plastic surgery in the treatment of recession defects, previous studies have reported that patients rate the esthetic outcomes more favorable than dental professionals. The root coverage esthetic score has been developed and suggested to serve as a comprehensive assessment instrument as it addresses several esthetic outcomes following root coverage procedures. However, no study has yet reported on patient use of this instrument. In the present study clinical, esthetic and patient-reported outcomes following periodontal plastic surgery were assessed. The primary objective was to compare the esthetic/clinical outcome as judged by the patient and by one dentist by using the root coverage esthetic score. The secondary objective was to evaluate the correlation between patient-reported outcomes, root coverage esthetic score and clinical parameters following treatment of recession defects.

Materials and methods

Subjects that had undergone periodontal plastic surgery were invited to score the treatment outcome according to the root coverage esthetic score, which subsequently also was professionally scored by a dentist. Thereafter, the subjects answered a questionnaire on patient satisfaction. All types of surgical root coverage procedures in canine or incisor teeth were included.

Results

A total of 34 subjects were included, presenting 46 treated recessions. No statistically significant different score was found comparing the root coverage esthetic score by the patient and the professional. The majority of subjects was satisfied with the treatment outcome, and most would have undergone the treatment again.

Conclusion

The root coverage esthetic score assessment can be conducted by patients and was not statistically significant different to that of the professional. Patient satisfaction is not always dependent on complete root coverage or the other clinical parameters included in the root coverage esthetic score.

Factors influencing the aesthetics of smile: An observational study on clinical assessment and patient's perception

AIM

To clinically assess the aesthetics of smile and the possible influencing factors.

MATERIALS AND METHODS

In this explorative study, an initial questionnaire on demographic variables and perception of own quality of smile (Visual Analogue Scale) was administered by a first examiner. A second blinded assessor examined all patients and recorded clinical data. In addition, for each patient, the Smile Aesthetic Index (SEI) was calculated. Descriptive statistics and multilevel logistic models were performed.

RESULTS

One hundred consecutive subjects were enrolled. The mean SEI was 8.4 ± 1.2, while the mean patient's perception of smile was 7.1 ± 2.0. However, they did not correlate (r = 0.16 from -0.04 to 0.34; p = .12). Gingival recessions were perceived by 21.9% of subjects, tooth alignment by 38.6%, tooth dyschromia by 34.3%, and missing papilla/diastema by 26.7%. In particular, gingival recessions were perceived when they were deeper (p = .0342), located in the upper jaw (p = .0223), and corresponding to incisors (p < .0001) and canines (p = .0159) with respect to molars.

CONCLUSIONS

Clinical assessment and patient perception represent two important diagnostic phases. However, there is no correlation between them. Attention should be given to specific variables to provide the most comprehensive aesthetic analysis of smile.

Assessment of Patients’ Satisfaction following Coverage of Gingival Recessions: Questionnaire-Based Case Series

Background/Aim: One of the most important goals of periodontal plastic surgery constitutes the predictable root coverage. Despite the thorough documentation that several surgical approaches can be implemented for the successful treatment of gingival recession (GR), only limited papers reported data on the evaluation according to patient’s opinion. Thus, the forthcoming study is aiming in the patient-based assessment of the outcome of root coverage procedures.

Material and Methods: Sixteen subjects (eight male, eight female; mean age 43.75 years, range: 23-73 years), with twenty one GRs, constituted the sample of this study and the root coverage procedures were executed in the period from 2011 to 2019. A patient-based questionnaire was used to assess the level of subjects’ concern on various aspects related to the GR, preand post-operatively. Patient’s overall post-operative satisfaction was evaluated with a VAS.

Results: After a period of at least 6 months of the surgical treatment, the majority of the subjects indicated that they were not concerned for all the examined criteria. The criteria with the highest improvement (reported as improvement by at least two levels of concern pre- and post-operatively) were the following: 1) fear to lose the involved teeth and 2) esthetics of the area of the recession defect. With regard to esthetics’ criteria, the majority of the patients indicated post-operatively the examined criteria as not important. The esthetics’ criteria yielding the highest improvement were: 1) position of the teeth and 2) the fact that the teeth showed longer. Mean patient’s overall post-operative satisfaction was 82,3 (range: 0-100).

Conclusions: The majority of the subjects were satisfied from the implemented root coverage procedures. Few studies on the international literature have evaluated patient satisfaction following therapy. Comprehensive, multi-center studies, comprised of a large sample and a using a standardized approach are needed in future research.

Analysis of root coverage esthetic score in patients treated for gingival recession: An interexaminer reliability

Background:

Awareness about pink esthetics among dentists in general needs to be assessed as root coverage procedures are the mainstay of treatment for gingival recession. Concordance among the dentists in figuring out the esthetic outcomes after root coverage procedures is inconsistent. Hence, this study aims to evaluate inter- and intra-examiner reliability of root coverage esthetic scores (RES) between periodontists and nonperiodontists.

Materials and Methods:

The study was conducted using twenty baseline and 6-month posttreatment photographs of Miller's Class I and Class II gingival recessions. The participants that constituted ten periodontists and ten nonperiodontists were assembled in the seminar hall to receive training on protocol and procedures for RES by the investigator. All the participants were shown twenty projections of side-by-side baseline and 6-month outcomes of root coverage procedures. Each projection was shown for 30 s during which the participants were made to use RES system to evaluate the surgical outcomes.

Results:

Periodontists showed the highest reliability in the scores of marginal tissue contour with an overall intraexaminer reliability to be perfect among periodontists. Intraexaminer reliability among nonperiodontists was fair, and gingival margin was the parameter with the highest reliability among them. Interexaminer reliability between periodontists and nonperiodontists showed slight reliability concerning gingival margin, and fair reliability was found for marginal tissue contour, soft-tissue texture, mucogingival junction, and gingival color.

Conclusion:

Satisfying the esthetic component of gingiva is the duty of every dentist in general and not only the periodontists. Significant variability was found in esthetic scores between the groups, which can probably be attributed to the lack of sufficient knowledge regarding pink esthetics among the nonperiodontists, which needs to be improved.

Complete root coverage in the treatment of Miller class III or RT2 gingival recessions: a systematic review and meta-analysis

Background

The primary objective of this systematic review and meta-analysis was to assess the evidence on complete root coverage (CRC) achieved by periodontal plastic techniques in the treatment of Miller class III/RT2 gingival recessions, comparing techniques developed along the twentieth century (pre-twenty-first) versus surgical approaches of the twenty-first century (21st).

Methods

An electronic bibliographic search was carried out in four databases up to December 2019, focusing on studies that reported CRC results in Miller class III or RT2 recessions treatment with at least a six-month follow-up. In addition, a random-effects models’ meta-analysis was performed for the CRC, comparing pre-twenty-first versus twenty-first century techniques at 6 months, 12 months and more than 12 months.

Results

Thirty-seven publications were included. A total of 933 gingival recessions were treated, 298 with pre-twenty-first century surgical techniques and 635 with techniques from the twenty-first century. CRC was achieved at 6 months on half of the recessions (pre-twenty-first: 57.60% vs. 21st: 51.11%), but decreased markedly for twenty-first century techniques at 12 months (pre-twenty-first: 63.82% vs. 21st: 32.87%). Thereafter, this difference was the other way around (> 12 months: pre-twenty-first: 5.26% vs. 21st: 19.65%). The meta-analysis showed a high heterogeneity, with no significant differences amongst the techniques.

Conclusions

Although CRC might be achievable by treating Miller class III or RT2 recessions with any of the described techniques, its long-term stability is not predictable. More randomized clinical trials with longer follow-ups and several visits, are needed. In addition, the patient’s satisfaction should also be assessed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01494-3.

Description of the modified vestibular incision subperiosteal tunnel access (m-VISTA) technique in the treatment of multiple Miller class III gingival recessions: a case series

Background

Gingival recession is a common finding in the adult population. It is considered a challenge for clinicians to obtain a complete root coverage of Miller class III recession. The aim of this case series was to assess the outcomes achieved with the use of modified VISTA technique (m-VISTA) in patients having multiple Miller class III recessions after 6 months.

Methods

Ten patients (six women and four men; mean age: 53 years), who showed multiple Miller class III recessions (depth ≥ 2 mm) and who met the established inclusion and exclusion criteria, were treated by postgraduate students with the use of m-VISTA technique.

Results

A total of 38 recessions were performed. The recessions were mainly located in the mandible (80%), which included six molars. The mean baseline recession was 3.12 mm. Post the intervention, a mean root coverage of 58.72% was achieved, with complete root coverage observed in 29% of the recessions.

Conclusions

m-VISTA may offer several advantages in the treatment of Miller class III gingival recession. Nevertheless, more clinical trials with a longer follow-up period are needed to arrive at a concrete conclusion about its advantages.

Trial registration: NCT03258996.

Data registration: 08/18/2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01511-5.

Smile esthetic evaluation of mucogingival reconstructive surgery

To assess the difference in smile esthetic impact of Coronally Advanced Flap (CAF) with or without the adjunct of a collagen matrix (CMX) used as root coverage procedures. Subjects with esthetic demands showing multiple upper gingival recessions of at least 2 mm, without interproximal attachment loss and cervical abrasion no more than 1 mm were recruited and randomized to CAF plus CMX or CAF alone. The Smile Esthetic Index (SEI) was adopted to quantify the quality of the smile recorded at baseline and 12 months after treatment for each treatment group. In addition, between group difference in the SEI was calculated. 24 Patients were treated and analysed. At baseline, mean gingival recession depths were 2.3 ± 0.7 mm for Test group and 2.6 ± 1.0 mm for Control group. After 1 year, the residual recession depth was 0.3 ± 0.4 mm in the CAF + CMX group and 0.6 ± 0.3 mm in the control group. The SEI at baseline was 8.1 ± 1.0 and 7.9 ± 0.7 for Test and Control group, respectively. The between groups difference at 12 months in SEI was 0.4 (95% C.I. − 0.0 to 0.8, P = 0.0697). Twelve months after treatment, CAF + CMX provided a similar SEI compared to CAF alone and the adjunct of a collagen matrix did not show a different impact on the smile esthetic appearance.

Root coverage procedures for treating localised and multiple recession-type defects

BACKGROUND

Gingival recession is defined as the oral exposure of the root surface due to a displacement of the gingival margin apical to the cemento-enamel junction and it is regularly linked to the deterioration of dental aesthetics. Successful treatment of recession-type defects is based on the use of predictable root coverage periodontal plastic surgery (RCPPS) procedures. This review is an update of the original version that was published in 2009.

OBJECTIVES

To evaluate the efficacy of different root coverage procedures in the treatment of single and multiple recession-type defects.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 12) in the Cochrane Library (searched 15 January 2018), MEDLINE Ovid (1946 to 15 January 2018), and Embase Ovid (1980 to 15 January 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 January 2018). No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) only of at least 6 months' duration evaluating recession areas (Miller's Class I or II ≥ 3 mm) and treated by means of RCPPS procedures.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, data extraction and risk of bias assessment were conducted independently and in duplicate. Authors were contacted for any missing information. We expressed results as random-effects models using mean differences (MD) for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). We used GRADE methods to assess the quality of the body of evidence of our main comparisons.

MAIN RESULTS

We included 48 RCTs in the review. Of these, we assessed one as at low risk of bias, 12 as at high risk of bias and 35 as at unclear risk of bias. The results indicated a greater reduction in gingival recession for subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to guided tissue regeneration with resorbable membranes (GTR rm) + CAF (MD -0.37 mm; 95% CI -0.60 to -0.13, P = 0.002; 3 studies; 98 participants; low-quality evidence). There was insufficient evidence of a difference in gingival recession reduction between acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix protein (EMP) + CAF and SCTG + CAF. Regarding clinical attachment level changes, GTR rm + CAF promoted additional gains compared to SCTG + CAF (MD 0.35; 95% CI 0.06 to 0.63, P = 0.02; 3 studies; 98 participants; low-quality evidence) but there was insufficient evidence of a difference between ADMG + CAF and SCTG + CAF or between EMP + CAF and SCTG + CAF. Greater gains in the keratinized tissue were found for SCTG + CAF when compared to EMP + CAF (MD -1.06 mm; 95% CI -1.36 to -0.76, P < 0.00001; 2 studies; 62 participants; low-quality evidence), and SCTG + CAF when compared to GTR rm + CAF (MD -1.77 mm; 95% CI -2.66 to -0.89, P < 0.0001; 3 studies; 98 participants; very low-quality evidence). There was insufficient evidence of a difference in keratinized tissue gain between ADMG + CAF and SCTG + CAF. Few data exist on aesthetic condition change related to patients' opinion and patients' preference for a specific procedure.

AUTHORS' CONCLUSIONS

Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration may be used as root coverage procedures for treating localised or multiple recession-type defects. The available evidence base indicates that in cases where both root coverage and gain in the width of keratinized tissue are expected, the use of subepithelial connective tissue grafts shows a slight improvement in outcome. There is also some weak evidence suggesting that acellular dermal matrix grafts appear as the soft tissue substitute that may provide the most similar outcomes to those achieved by subepithelial connective tissue grafts. RCTs are necessary to identify possible factors associated with the prognosis of each RCPPS procedure. The potential impact of bias on these outcomes is unclear.

Micro- and macrosurgical techniques in the coverage of gingival recession using connective tissue graft: 2 years follow-up

OBJECTIVE

The aim was to evaluate the clinical results of micro- and macrosurgical approaches in the coverage of gingival recession using connective tissue graft.

MATERIAL AND METHODS

Twenty-one teeth in microsurgical group (test group) and 21 in macrosurgical group (control group) were treated using coronally positioned flap and subgingival connective tissue graft. Recession depth (RD), recession width (RW), root surface area (RSA), keratinized tissue width (KTW), probing depth, clinical attachment level, pain level during healing, and aesthetic results were evaluated for 24 months.

RESULTS

RD, RW, and RSA were significantly lower at 1, 3, 6, and 24th months compared with baseline in both groups. RD was also significantly lower in the 1st month compared with 24th month in control group. RD and RSA at 24th month were significantly lower in microsurgical group. KTW significantly and similarly increased by 6th month in both groups. The pain levels in the donor and the recipient area decreased earlier in the microsurgical group, and aesthetic scores improved similarly in both groups.

CONCLUSION

A microsurgical approach to root coverage with gingival recession is likely to preserve the clinical outcomes longer than macrosurgical approach, at least for 24 months. Healing appears to be faster using microsurgery, but aesthetic outcomes are similar.

CLINICAL SIGNIFICANCE

This study evaluated the clinical results of microsurgical versus macrosurgical approaches to root coverage in cases of gingival recession. Based on the results of the study, pain levels in the donor and the recipient areas decreased earlier in the microsurgical group, and microsurgical approach resulted in significantly greater amount of root coverage at 24 months.

Coronally advanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience

During the past three decades, several surgical techniques have been proposed to treat single and multiple gingival recessions. Evidence indicates that coronally advanced flap-based approaches result in the best clinical results. Among all the different techniques, the use of a graft under a coronally advanced flap results in the best short- and long-term outcomes in terms of root coverage and gain in keratinized tissue. The use of a coronally advanced flap + connective tissue graft would appear to be the best choice for root coverage. However, harvesting a graft from the palate adds morbidity, surgical chair-time and requires increased surgical skills. A potential alternative could be the use of enamel matrix derivatives under a coronally advanced flap, and this achieves similar clinical outcomes and is less invasive, but adds economic costs to the treatment. Evidence shows that a coronally advanced flap alone in many instances results in complete root coverage and is stable over time. A coronally advanced flap is less invasive for the patient, requires less chair-time and probably less surgical skill. It would therefore be desirable to use a coronally advanced flap approach when indicated. It has been hypothesized that a coronally advanced flap approach alone could be successfully applied when the residual gingiva is thick and wide, although existing evidence does not support this hypothesis in full. Accordingly, the adjunctive use of a graft or enamel matrix derivatives could be restricted to sites at which there is thin and narrow residual gingiva.

Classification of dental surface defects in areas of gingival recession

BACKGROUND

A clinical classification of surface defects in gingival recession area is proposed.

METHODS

Two factors were evaluated to set up a classification system: presence (A) or absence (B) of cemento-enamel junction (CEJ) and presence (+) or absence (-) of dental surface discrepancy caused by abrasion (step). Four classes (A+, A-, B+, and B-) were identified on the basis of these variables. To validate the classification three different calibrated examiners applied the proposed classification system to 46 gingival recessions and kappa statistics were performed. The classification was used on 1,010 gingival recessions from 353 patients to examine the distribution of the four classes.

RESULTS

The kappa statistics for intrarater agreement ranged from 0.74 to 0.95 (almost perfect agreement), whereas interrater agreement ranged from 0.26 to 0.59 (moderate agreement). Out of 1,010 exposed root surfaces associated with gingival recession, 144 showed an identifiable CEJ associated with a root surface defect (Class A+, 14%); 469 an identifiable CEJ without any associated step (Class A-, 46%); 244 an unidentifiable CEJ with a step (Class B+, 24%); and 153 an unidentifiable CEJ without any associated step (Class B-, 15%).

CONCLUSION

The proposed classification describes the dental surface defects that are of paramount importance in diagnosing gingival recession areas.

A clinical comparison of two flap designs for coronal advancement of the gingival margin: semilunar versus coronally advanced flap

BACKGROUND

The semilunar incision was introduced in oral surgery more than a century ago. The semilunar coronally re-positioned flap (SLCRF) is one of the variants of this procedure; however, no previous controlled clinical study has evaluated the SLCRF performed as originally described. The objective of the present study was to compare the clinical outcomes of the SLCRF and coronally advanced flap (CAF) procedure in the treatment of maxillary Miller class I recession (GR) defects.

MATERIALS AND METHODS

Twenty-two patients, with 22 contra-lateral Miller class I GR defects, were randomly assigned to CAF or SLCRF. Clinical parameters assessed included recession height, width of keratinized tissue, probing depth, vertical clinical attachment level, visual plaque score and bleeding on probing. Clinical recordings were performed at baseline and 6 months later. Inter-measurements differences were analysed with a chi(2) or a paired t-test, with significance set at alpha<0.05.

RESULTS

Both flap designs were effective in obtaining and maintaining a coronal displacement of the gingival margin. The CAF resulted in clinical improvements significantly better than SLCRF for percentage of root coverage (RC), frequency of complete RC and gain in clinical attachment level. RC obtained in the immediate post-surgical period of SLCRF-treated sites was not maintained throughout the subsequent evaluations.

CONCLUSION

RC is significantly better with CAF compared with the original SLCRF technique in the treatment of shallow maxillary Miller class I GR defects.

Qualitative cosmetic evaluation after root-coverage procedures

BACKGROUND

The purpose of the present study was to evaluate the esthetic outcome using four categories of root-coverage procedures (pedicle soft tissue grafts, non-submerged grafts, submerged grafts, and envelope techniques) and to identify factors associated with esthetic assessment.

METHODS

A professional panel of three observers (two periodontists and one control) used a before-after panel scoring system to evaluate the esthetics of 162 root-coverage surgeries. A five-point ordinal scale was used to evaluate the overall esthetic improvement and seven variables that may be considered in the assessment.

RESULTS

The intraobserver agreement of the two trained periodontists for the overall cosmetic assessment was almost perfect (kappa = 0.83), and substantial agreement was found between them (kappa = 0.68). Good to excellent overall esthetic results were found by the professionals and control in >70% of the surgical procedures. Analysis of variance indicated a statistical difference between the non-submerged grafts category and the three other surgical categories (P <10(-3)). Multivariate analysis showed that the degree of root coverage was not a significant predictive factor, whereas soft tissue appearance variables and the follow-up were significantly associated with cosmetic assessment.

CONCLUSIONS

The present study demonstrated that non-submerged grafts are not recommended in cases of esthetic demand. Future root-coverage trials, basing their justification on esthetics, should include overall qualitative evaluation as the primary variable. The follow-up period should not be <12 months. The before-after panel scoring system is a tool that can be used to evaluate cosmetic outcomes.