J Periodontol December 2011

Case Series

Non-Carious Cervical Lesions Associated With Gingival Recessions: A Decision-Making Process

Giovanni Zucchelli,* Guido Gori, Monica Mele,* Martina Stefanini,* Claudio Mazzotti,* Matteo Marzadori,* Lucio Montebugnoli, and Massimo De Sanctis
Background: A method to predetermine the maximum root coverage level (MRC) was recently demonstrated to be reliable in predicting the position of the soft tissue margin after root coverage surgery. The aim of the present study is to suggest a decision-making process for treating non-carious cervical lesions (NCCLs) associated with gingival recessions based upon the topographic relationship between the MRC and NCCL and to assess patient and independent-periodontist esthetic evaluations. Methods: Five treatments were performed in 94 patients with NCCLs associated with a single gingival recession: 1) coronally advanced ap (CAF); 2) bilaminar procedure; 3) coronal odontoplasty plus restoration plus root odontoplasty plus CAF; 4) restoration plus CAF; and 5) restorative therapy. Clinical and esthetic evaluations made by the patient and an independent periodontist were done 1 year after treatments. Results: The satisfaction of the patient and periodontist with esthetics was very high in all NCCL treatments and Miller Class gingival recessions. The patient satisfaction and evaluation of root coverage and the periodontist evaluation of root coverage were statistically correlated with color-match evaluations and not with the amount of root coverage clinically achieved in each patient. Conclusion: The proposed approaches provided good esthetic appearance and correct emergence prole for the great majority of NCCLs associated with gingival recessions. J Periodontol 2011;82:1713-1724. KEY WORDS Cemento-enamel junction; gingival recession; surgery.
* Department of Periodontology, School of Dentistry, Bologna University, Bologna, Italy. Private practice, Rome, Italy. Department of Stomatology, Bologna University. Department of Periodontology, Siena University, Siena, Italy.

non-carious cervical lesion (NCCL) is described as the wear of the tooth substance at the level of the gingival one-third of the tooth due to reasons other than dental caries.1,2 Although an abrasion, due to mechanical forces,3 plays an important role in the development of NCCLs, it is not the sole cause, and it is generally accepted that the etiology of NCCLs is multifactorial, involving other factors such as corrosion, and possibly abfraction, as well.1,2 Main indications4 for the treatment of an NCCL are: 1) esthetics, especially when the lesion is pigmented and/or associated with gingival recession; 2) dentin hypersensitivity, which may be the cause of discomfort/pain or faulty plaque control for the patient; 3) caries/demineralization with or without dentin hypersensitivity; and 4) bacterial plaque accumulation due to the shape and/or depth of abrasion that make oral health care difcult/ineffective. From a topographic standpoint, an NCCL can involve only the crown of the tooth (enamel and/or coronal dentin) or only the root surface (cementum and/or root dentin), or it can occupy both the crown and exposed root. When the NCCL involves the root it is commonly associated with gingival recession. An NCCL involving
doi: 10.1902/jop.2011.110080

1713

Treatment of Non-Carious Cervical Lesions

Volume 82 Number 12

only the anatomic crown of the tooth should be treated with restorative therapy, whereas an NCCL limited to the root surface should be treated with mucogingival surgery. The true clinical context is more complex and, frequently, the NCCL involves both the crown and root, causing the disappearance of the cemento-enamel junction (CEJ), which anatomically separates the crown from the root.5 Thereafter, the main referring parameter for the selection of the therapeutic approach is no longer available. Furthermore, the anatomic distinction between crown and root does not always correspond to the clinical one and the entire exposed root surface is covered with soft tissues; this is the case with Miller Class6 III and IV gingival recessions. Furthermore, different local conditions at a tooth with gingival recession may limit the amount of root coverage, even in the absence of the loss of interdental periodontal support5 (i.e., the loss of the tip of the papilla or tips of papillae, tooth rotation, and tooth extrusion with or without occlusal wear). The ideal treatment of a crown-radicular NCCL should consist of a combined restorative/periodontal treatment. Completing the restorative therapy before mucogingival surgery leads to various clinical advantages for both procedures: the restoration that can be easily performed and nished in an isolated (with rubber dam) eld without interference of the soft tissues, and the root-coverage surgery is facilitated by the reconstruction of the clinical crown emergence prole that provides a stable, smooth, and convex substrate for the surgical ap. The main clinical concern is when to nish the composite restoration. Theoretically, the composite lling should be placed when gingival tissues are stable after the healing process of the mucogingival root coverage procedure. This position was described as the maximum root coverage level (MRC).7 This level is dened as a line (line of root coverage) that should coincide with the anatomic CEJ when it was not clinically detectable on the tooth with Miller Class I or II gingival recession or would be more apical than the anatomic CEJ when the ideal anatomic conditions to obtain complete root coverage were not fully represented (i.e., a Miller Class III gingival recession).5 A method to predetermine the MRC based on the calculation of the ideal height of the anatomic interdental papilla was demonstrated to be reliable in predicting the position of the soft tissue margin 3 months after root coverage surgery.7 The aim of the present pilot, case series study is to suggest a decision-making process for treating NCCLs associated with gingival recessions based upon the topographic relationship between the MRC and NCCL and to assess patient and independent-periodontist esthetic evaluations.
1714

MATERIALS AND METHODS Ninety-four patients (45 males and 49 females; age range: 20 to 48 years; mean age: 34.6 9 years) were enrolled in the study. Patients were selected on a consecutive basis among individuals referred to the School of Dentistry, University of Bologna, in the period between September 2007 and April 2008. The study protocol, questionnaires, and informed written consent is in full accordance with the ethical principles of the Declaration of Helsinki of 1975, as revised in 2000, were approved by an institutional review board and received the approval of the local ethics committee of Bologna University. All participants met the following study inclusion criteria: 1) aged >18 years; 2) periodontally and systemically healthy; 3) NCCL associated with a single Miller Class I, II, III, or IV gingival recession (rotated, malpositioned, extruded teeth with or without occlusal wear and teeth with some loss of papillae height5 were included in Miller Class III); 4) no contraindications for periodontal surgery; 5) not taking medications known to interfere with periodontal tissue health or healing; and 6) no previous periodontal surgery at involved sites. Teeth in which it was not possible to predetermine the MRC (the absence of a contact point in the tooth with gingival recession and in the homologous contralateral one) or that had prosthetic crowns or composite restorations extending on the facial root surface were excluded from the study. Patients who smoked >10 cigarettes a day were also excluded. Recession defects associated with evidence of pulpal pathology were not included, and molar teeth were excluded. Study Design This was a pilot, case-series study selecting different treatment approaches for NCCL associated with gingival recessions according to the topographic relationship between the MRC and NCCL. The study protocol involved a screening appointment to verify the diagnosis and Miller classication6 of gingival recession and eligibility (presence of an NCCL) followed by initial therapy to establish optimal plaque control and gingival health conditions, the predetermination of MRC, the selection of one of ve treatment approaches, treatments, the early maintenance phase, and the clinical and esthetic postoperative evaluation 1 year after treatment. An esthetic postoperative evaluation was made by an independent examiner (CM) and by the patient based on a visual analog scale (VAS) of 100 mm.8,9 Diagnosis of NCCL and Classication of Gingival Recessions NCCL was considered a loss of hard tissue localized in the gingival one-third of the tooth.1,2 A diagnosis of an NCCL was made by using a periodontal probe that

J Periodontol December 2011

Zucchelli, Gori, Mele, et al.

allowed for the realization of the presence of the most coronal step of the NCCL. The sharpness, depth, and at outline of the coronal step of the NCCL distinguished it from the anatomic CEJ. The examination of the prole of the target tooth conrmed the diagnosis of an NCCL and easily differentiated the coronal step of the NCCL from the CEJ. Gingival recessions were categorized into four classes according to the Miller classication.6 Initial Therapy After the screening examination, all patients received a session of prophylaxis including instructions in proper oral hygiene measures, scaling, and professional tooth cleaning with the use of a rubber cup and a low-abrasive polishing paste. A coronally directed roll technique was prescribed for teeth with recession defects to minimize toothbrushing trauma to the gingival margin. The treatment of the abrasion/recession defect was not scheduled until the patient was able to demonstrate an adequate standard of supragingival plaque control. Clinical Measurements All clinical measurements were carried out by a single, masked examiner (MM) at baseline and 1 year postsurgery. MM did not perform the surgeries and was unaware of the treatment assignment. Before the study, the examiner was calibrated to reduce intraexaminer error (k >0.75) to establish reliability and consistency. The full-mouth plaque score was recorded as the percentage of total surfaces (four aspects per tooth), which revealed the presence of plaque.10 Bleeding on probing (BOP) was assessed dichotomously at a force of 0.3 N with a manual pressure-sensitive probe.i The full-mouth bleeding score was recorded as the percentage of total surfaces (four aspects per tooth) that revealed the presence of BOP. The following clinical measurements were taken 1 week before the surgery and at the 1-year follow-up at the mid-facial aspect of the study teeth: 1) local (facial) plaque score assessed dichotomously (yes/ no); 2) local (facial) bleeding score assessed dichotomously (yes/no); 3) distance between the incisal margin and gingival margin (IMGM); 4) probing depth (PD), measured from the gingival margin to the bottom of gingival sulcus; and 5) height of keratinized tissue (KTH), which was the distance between the gingival margin and mucogingival junction. The mucogingival junction was identied by means of Lugol staining. Measurements of the IMGM distance, PD, and KTH were performed by using a manual probe and were rounded up to the nearest millimeter. Patient Esthetic Evaluation Patient satisfaction with esthetics was evaluated at the 1-year follow-up visit based on a VAS. Patients were

asked to select among 100 scores (0 = very bad, 50 = average, and 100 = excellent) in terms of overall satisfaction, color match, and root coverage.9,11,12 Objective Evaluation of Esthetics The objective evaluation of root coverage (the presence of exposed root or NCCL), color match between hard (tooth/composite) and soft tissues, and tooth emergence prole (capable of protecting the soft tissue margin and easy to clean by the patient) were scored at the 1-year post-surgical evaluation visit by another expert periodontist (CM), who was unaware on the treatment performed. The periodontist was asked to rate the root coverage, color match, and tooth emergence prole among 100 VAS scores (0 = very bad, 50 = average, and 100 = excellent).9,11,12 Predetermination of MRC The method used to predetermine the MRC in teeth with NCCL associated with gingival recessions was recently published by our research group.7 The method was based on the calculation of the ideal height of the anatomic interdental papilla.5 In brief, the ideal height of the papilla was measured as the distance between the point in which the CEJ crossed the facial mesial-distal line angle of the tooth (CEJ angular point) and the contact point. The CEJ angular point is easily identiable, even in a tooth with an NCCL, by elevating the interdental soft tissues (with a probe or small spatula) and searching for the interdental CEJ. Once the ideal papilla was measured, this dimension was replaced apically starting from the tips of the mesial and distal papillae of the tooth with the recession defect. The horizontal projections on the recession margin of these measurements allowed for the identication of two points that were connected by a scalloped line that represented the line of root coverage. The MRC was considered the most apical extension of the line of root coverage. The predetermination of the MRC was performed by a single, masked examiner (MM) 1 week before the treatment. The examiner (MM) did not perform the treatment. Determination of Treatment Alternatives (NCCL types) The examiner categorized the gingival-NCCL defects in ve types in relation to the position of the MRC with respect to the NCCL (Fig. 1): type 1; the MRC was located >1 mm coronal to the most coronal extension of the NCCL, type 2; the MRC was located 1 mm coronal to the most coronal extension of the NCCL, type 3; the MRC was located in the deepest portion of the NCCL, type 4; the MRC was located apical to the
i PCP UNC-15 probe tip, Hu-Friedy, Chicago, IL; equipped with a Brodontic spring device, Dentramar, Waalwijk, The Netherlands.

1715

Treatment of Non-Carious Cervical Lesions

Volume 82 Number 12

deepest portion of the NCCL, and type 5; the MRC was located at the level or apical to the most apical extension of the NCCL. Treatments Conservative therapy was performed by a single, masked experienced restorative dentist (GG). Surgical therapy was performed by a single, masked experienced periodontist (GZ). The adopted surgical techniques consisted of a trapezoidal coronally advanced ap (CAF) as a root coverage procedure13 or as covering ap of a subepithelial connective tissue graft in the bilaminar technique.14 Five different treatment approaches were adopted according to the NCCL type. Type 1. NCCL type 1 was a radicular NCCL associated with a Miller Class I (Fig. 2) or II gingival recession. In this clinical situation, the amount of tooth surface comprised between the MRC and the coronal step of the NCCL was greater than the maximum mistake (1 mm) in the calculation of the MRC.7 The treatment was exclusively periodontal. The NCCL/gingival recession was treated by means of a CAF root coverage surgical procedure during which the exposed root surface (including the NCCL) was treated mechanically (with hand and/or rotating instruments) to obtain a hard, smooth, and regularly concave surface and chemically (24% EDTA for 2 minutes) to eliminate the smear layer. At the end of the surgery, the ap was coronally advanced 1 mm in excess with respect to the MRC.

Type 2. NCCL type 2 was also a radicular NCCL associated with a Miller Class I or II (Fig. 3) gingival recession, but in this case, there was not enough space between the MRC and coronal step of the NCCL to compensate for errors in the calculation of the MRC and/or the post-surgical soft tissue shrinkage. Therefore, there was a risk of soft tissues collapse into the abrasion space. In this case too, the treatment of the NCCL/gingival recession was exclusively periodontal. The NCCL was mechanically and chemically treated during mucogingival surgery, but in this case, the root coverage procedure consisted in a bilaminar technique (i.e., a connective tissue graft covered by a CAF). The connective tissue graft (harvested from the palate) was positioned inside the root concavity. The graft thickness lled the abrasion space and prevented the collapse of the covering soft tissue ap inside it. The graft, by acting as a ller or space-keeping inside the concave abrasion area, provided stability and sustained the covering ap, which was coronally advanced 1 mm in excess with respect to the MRC. Type 3. NCCL type 3 was a crown-radicular NCCL associated with a Miller Class I (Fig. 4), II, or III gingival recession. This was the most complex type, particularly when the abrasion defect was deep (1 mm) and narrow. A coronal (performed before the restorative treatment) and radicular (performed during the mucogingival surgery) odontoplasty was done to reduce the depth and increase the height of the

Figure 1.
A chart illustrating the decision-making process for treating NCCLs associated with gingival recessions. A) Lateral view of an NCCL associated with gingival recession. B) NCCL type 1: the MRC (arrow) was located >1mm coronal to the coronal step of the NCCL. The treatment consisted of a coronally advanced pedicle ap. The space between the covering ap and the root concavity was occupied by blood coagulum (red area). C) NCCL type 2: the MRC (arrow) was located at the level of the coronal step of the NCCL. The treatment consisted of a bilaminar technique: a connective tissue graft (pink area) covered by a CAF . The graft acted as a space maintainer and sustained the CAF, preventing its collapse inside the abrasion space. D) NCCL type 3: the MRC (arrow) was located in the deepest portion of the abrasion defect. The treatment consisted of a coronal and radicular odontoplasty composite restoration (light-blue area) nished at the level of the MRC and CAF. The shallow space between the covering ap and root concavity, apical to the MRC, was occupied by blood coagulum (red area). E) NCCL type 4: the MRC (arrow) was located apical to the deepest portion of the abrasion defect due to a mild loss of papilla height (black area). The treatment consisted of a composite restoration (light-blue area) nished at the level of the MRC and CAF. The shallow space between the covering ap and the root concavity apical to the MRC was lled with blood coagulum (red area). F) NCCL type 5: the MRC (black arrow) was located at the level of the most apical extension of the NCCL due to a severe loss of papilla height (black area). The treatment consisted of a composite restoration (light-blue area) nished at the level of the MRC and a repositioned ap or CAF.

1716

J Periodontol December 2011

Zucchelli, Gori, Mele, et al.

NCCL. The coronal odontoplasty reduced the sharpness and depth of the coronal step of the NCCL and was extended more and more occlusally with the increasing depth of the hard tissue defect. The grinded area was restored with a composite lling that was extended up to the MRC. The coronal odontoplasty made at the level of the enamel created a long bevel

that improved the adhesion of the restorative material. The exposed root surface apical to the MRC was used for isolating the operative eld by a rubber dam. If and when the NCCL reached or extended beyond the soft tissue margin, it was necessary to the elevate the ap before performing the composite restoration to expose some root surface apical to NCCL, which was necessary for isolating the operative eld with the rubber dam. The root odontoplasty was performed during surgery to further reduce the depth of the NCCL. It was performed with rotating burs and was completed with manual instruments as far as a correct tooth emergence prole was obtained. The prole of the composite was used as a guide for the correct planning of the root surface. Once the root odontoplasty was completed, a pedicle ap was coronally advanced 1 mm in excess with respect to the apical extension of the composite lling. The conservative llFigure 2. ing facilitated the surgery by NCCL type 1. A) Canine with gingival recession and a shallow radicular NCCL defect. The hard tissue defect was completely coverable with soft tissues. B) Root surface and NCCL area were mechanically treated providing a smooth, convex, after a ap elevation. C) The ap was coronally advanced and sutured coronal to the CEJ. D) One-year and stable substrate for the corfollow-up after the CAF surgical technique: complete root coverage and a good emergence prole were onal stabilization of the surgical obtained. The NCCL defect appeared to be lled by an increased facial soft-tissue thickness. ap.

Figure 3.
NCCL type 2. A) Canine with gingival recession and a deep NCCL defect. The defect was coverable with soft tissues. B) A connective tissue graft was positioned and sutured within the NCCL space. The graft acted as space-maintaining material preventing the collapse of the covering ap inside the NCCL defect. C) The ap was coronally advanced and sutured coronal to the CEJ. D) One-year follow-up after a bilaminar technique: complete root coverage and a good emergence prole were achieved. The NCCL space was lled by the increased thickness of facial gingival tissues. 1717

Treatment of Non-Carious Cervical Lesions

Volume 82 Number 12

the rubber dam was applied after elevating the ap. Mucogingival surgery, consisting of a CAF technique, was used to cover that portion of the root exposure apical to the composite lling. The ap was advanced 1 mm coronal to the apical extension of the composite lling. Type 5. NCCL type 5 was a radicular NCCL associated with a Miller Class III and IV gingival recession (Fig. 6). The NCCL was located on that portion of the root surface that was not coverable with soft tissues. Therefore, treatment of the defect was exclusively restorative. The root coverage surgery (if feasible, as with a Miller Class III gingival recession) might have proceeded independently from the restorative therapy, although it is always recommended that the restoration be performed rst so as not to render the isolation of the operative eld more difcult due to the more coronal location of the soft tissues. If and when the NCCL reached or extended beyond the soft tissue margin (Fig. 6), it was necessary to the elevate the ap before performing the composite restoration to expose the root surface apical to the NCCL, which was necessary for isolating the operative eld with the rubber dam. The surgical ap was positioned 1 mm coronal to the apical extension of the composite lling. Post-Surgical Instructions and Infection Control Postoperative pain and edema were controlled Figure 4. with ibuprofen. Patients received a 600 mg tablet NCCL type 3. A) Upper canine with gingival recession and a deep NCCL defect. at the beginning of the surgical procedure and The defect involved the crown and root resulting in disappearance of the were instructed to take another tablet 6 hours anatomic CEJ. The MRC was located within the deepest portion of the abrasion later. Subsequent doses were taken only if necesdefect. B) The depth of the NCCL was reduced by means of a coronal odontoplasty, and the crown emergence prole was restored with a composite lling. C) Flap sary to control pain. Patients were instructed not elevation. D) The prole of the composite was used as a guide for the correct to brush in the treated area but to rinse with a planning of the root surface (root odontoplasty). E) The ap was coronally advanced 0.12% chlorhexidine solution three times a day and secured coronal to the most apical extension of the composite restoration. The for 1 minute. Fourteen days after the surgical conservative therapy facilitated the surgery by providing a smooth, convex, and treatment, sutures were removed. Plaque control stable substrate for the coronal stabilization of the surgical ap. F) One-year follow-up: a tooth emergence prole that was easy for the patient to clean and in the surgically treated area was maintained by protecting the soft tissue margin was obtained. chlorhexidine rinsing for an additional 2 weeks. After this period, patients were again instructed in mechanical tooth cleaning of the treated tooth using Type 4. NCCL type 4 was a radicular NCCL assoan ultrasoft toothbrush and a roll technique for 1 month. ciated with Miller Class III gingival recessions or During this period, chlorhexidine rinse was used twice a crown-root NCCL associated with Miller Class I daily. Then, the patient started to use a soft-toothbrush or II gingival recession (Fig. 5) in which the deepest and to rinse with chlorhexidine once a day. All patients portion of the NCCL defect was localized at the were recalled for prophylaxis 2 and 4 weeks after suture level of the anatomic crown and only the apical porremoval and, subsequently, once every 2 months until tion of the NCCL involved the root. In both of the nal examination (12 months). these circumstances, the deepest portion of the NCCL was not coverable with soft tissue; thus, it Data Analyses was treated with the composite lling that was A statistical application software was used for extended up to the MRC. The exposed root surface the statistical analysis. Descriptive statistics were apical to the MRC was used for isolating the operative eld by a rubber dam. If this was not feasible, SAS version 6.09, SAS Institute, Cary, NC.
1718

J Periodontol December 2011

Zucchelli, Gori, Mele, et al.

RESULTS A total of 94 gingival recessions were treated. There were 26 Miller Class I recessions, 20 Miller Class II recessions, 38 Miller Class III recessions (including rotated or malpositioned and extruded teeth with or without an occlusal abrasion and teeth with some loss of papillae height), and 10 Miller Class IV recessions. There were 15 (16%) type 1 NCCLs, of which 10 were associated with Miller Class I gingival recessions, and ve NCCLs were associated with Miller Class II gingival recessions; 18 (19%) type 2 NCCLs, of which eight were asFigure 5. NCCL type 4. A) Upper canine with a shallow NCCL and deep gingival recession. The NCCL area involved sociated with Miller Class I ginthe crown and root causing the disappearance of the anatomic CEJ. The MRC was located apical to the gival recessions, and 10 NCCLs deepest portion of the abrasion defect. B) A composite lling restored the deepest portion of the NCCL were associated with Miller Class defect and was nished at the level of the MRC. A good emergence prole was obtained. C) The portion II gingival recessions; 27 (29%) of the hard tissue defect apical to the MRC was planned after a ap elevation. D) The prole of the type 3 NCCLs, of which four were restoration well supported the CAF, which was sutured coronal to the most apical extension of the composite lling. E) One-year follow-up after a composite restoration and CAF: a good tooth emergence associated with Miller Class I prole was obtained. Note that the coronal portion of the abrasion space was lled with composite, gingival recessions, three were whereas the apical part seemed to be lled by the increased thickness of the facial gingival tissue. associated with Miller Class II gingival recessions, and 20 NCCLs were associated with Miller expressed as means SDs. General linear models Class III gingival recessions; 19 (20.2%) type 4 were tted, and multiple regression one-way analysis NCCLs, of which four were associated with the Miller of variance (ANOVA) for repeated measures with a Class I gingival recessions, two were associated with split-plot design was used to evaluate the existence Miller Class II gingival recessions, and 13 were assoof any signicant difference regarding local plaque, ciated with Miller Class III gingival recessions; and 15 local bleeding, IMGM distance, KTH, and PD among (16%) type 5 NCCLs, of which ve were associated NCCL types or Miller Classes, time (1 year versus with Miller Class III gingival recessions, and 10 were baseline), and the interaction between NCCL types associated with Miller Class IV gingival recessions. or Miller Classes and time. In case of signicance, the Bonferroni t test was applied as a multiple-comOral Hygiene parison test. After the initial oral hygiene phase and at post-treatment After controlling for standardized skewness and examinations, all patients showed low frequencies of standardized kurtosis values for satisfaction, the plaque-harboring tooth surfaces (full-mouth plaque color match and root coverage by the patient and score <20%) and bleeding gingival units (full-mouth color match, emergence prole, and root coverage bleeding score <15%), indicating a good standard of by the periodontist were all within the range expected supragingival plaque control during the study period. for data from a normal distribution; one-way ANOVA The results of tting a general linear statistical was used to evaluate the presence of any signicant model relating local plaque to NCCL types, time, difference among NCCL types and Miller Classes. and the interaction between NCCL types and time The Fisher least-signicant difference procedure was showed high R2 statistics indicating that the model used to discriminate among means. as tted was signicant (F = 1.6; P <0.02) and exMultiple linear regression models were tted to plained 66% of the variability. A signicant relationdescribe the relationship between patient overall ship was found regarding time-related differences satisfaction as well as patient and periodontist eval(F = 26.8l P <0.01), whereas no signicant difference uations of root coverage and patient and periodonwas found concerning NCCL types or the interaction tist evaluations of color match and root coverage between NCCL types and time. At baseline, local (fa(in millimeters) that were clinically achieved with cial) plaque was demonstrated in 26 (28%) treated the surgery. sites. Local bleeding was recorded in 22 (23%) sites.
1719

Treatment of Non-Carious Cervical Lesions

Volume 82 Number 12

Figure 6.
NCCL type 5. A) Canine with gingival recession and a deep NCCL. The hard tissue defect involved the crown and root causing the disappearance of the anatomic CEJ. Tooth rotation and the reduction in papillae height limited the amount of coverable root; thus, the MRC was located at the level of the apical extension of the abrasion defect. B) After the ap elevation and rubber-dam application, a composite lling restored the entire NCCL defect and was nished at the level of the MRC. A good emergence prole was obtained. C) The composite restoration well supported the CAF, which was sutured coronal to the most apical extension of the composite lling. D) One-year follow-up after the composite restoration and CAF: a good tooth emergence prole was obtained. Compared to the baseline situation, the length of the clinical crown was slightly reduced.

One year after treatment, no local bleeding sites were present and only three (3%) sites were positive for the presence of plaque, indicating a marked improvement in plaque control by patients. No statistically signicant difference was demonstrated in local plaque at 1 year among NCCL types. Clinical Changes at 1 Year IMGM distance. The results of tting a general linear statistical model relating the IMGM distance to NCCL
1720

types, time, and the interaction between NCCL types and time showed high R2 statistics, indicating that the model as tted was highly signicant (F = 22.16; P <0.01) and explained 96% of the variability. Signicant relationship were found regarding time-related differences (F = 848.3; P <0.01), NCCL types (F = 72.0; P <0.01), and the interaction between NCCL types and time (F = 43.8; P <0.01). A statistically signicant reduction in the IMGM distance was demonstrated when comparing baseline (13.3 1.1 mm) and 1-year (11.2 2.3 mm) results. The overall mean root coverage amounted to 2.07 1.12 mm. The results of tting a general linear statistical model relating the IMGM distance to Miller Classes, time, and the interaction between Miller Classes and time showed high R2 statistics, indicating that the model as tted was highly signicant (F = 21.1; P <0.01) and explained 96% of the variability. Signicant relationships were found regarding time-related differences (F = 247.7; P <0.01), Miller Classes (F = 18.8; P <0.01), and the interaction between Miller Classes and time (F = 30.9; P <0.01). The baseline and 1-year post-surgical facial aspects of different NCCL types are shown in Figures 7 and 8, respectively. The mean root coverage in different NCCL types and Miller Classes are shown in Table 1. KTH. Results of tting a general linear statistical model relating KTH to NCCL types, time, and the interaction between NCCL types and time showed high R2 statistics, indicating that the model as tted was highly signicant (F = 3.2; P <0.01) and explained 78% of the variability. Signicant relationships were found regarding timerelated differences (F = 94.7; P <0.01), NCCL types (F = 20.3; P <0.01), and the interaction between NCCL types and time (F = 12.8; P <0.01). A statistically signicant increase in the KTH was demonstrated comparing baseline (1.58 0.62 mm) with 1-year (2.35 0.8 mm) KTH mean values. The overall increase in keratinized tissue amounted to 0.76 0.86 mm. The results of tting a general linear statistical model relating the KTH to Miller Classes, time, and the interaction between Miller Classes and time showed high R2 statistics, indicating that the model as tted was highly signicant (F = 2.8; P <0.01) and explained 75% of the variability. A signicant relationship were found regarding time-related differences (F = 63.5; P <0.01), Miller Classes (F = 6.16; P <0.01), and the interaction between Miller Classes and time (F = 3.9; P <0.01). The mean keratinized tissue increase in different NCCL types and Miller Classes are shown in Table 2. PD. Results of tting a general linear statistical model relating PD to time, NCCL types, and Miller Classes did not show any statistically signicant differences. The 1-year mean facial PD (1.2 0.3 mm) remained shallow with no statistically signicant change

J Periodontol December 2011

Zucchelli, Gori, Mele, et al.

Figure 7.
Baseline frontal view : A) NCCL type 1. B) NCCL type 2. C) NCCL type 3. D) NCCL type 4. E) NCCL type 5.

Figure 8.
One-year frontal views. A) NCCL type 1. B) NCCL type 2. C) NCCL type 3. D) NCCL type 4. E) NCCL type 5.

Table 1.

Mean Root Coverage

Root Coverage (mm) NCCL type Miller Class 1 3.06 0.79 1 2.69 0.67 2 3.33 0.59 II 3.1 1.07 3 1.92 0.54 III 1.55 0.6 4 1.47 0.51 IV 0.4 0.69 5 0.6 0.73

with respect to the baseline mean value (1.1 0.3 mm). Patient Satisfaction(VAS) Patient satisfaction with esthetics was very high in all types of treatment. Results from the multiple-regression ANOVA relating the patient satisfaction and patient evaluation of root coverage to the color match and root coverage clinically achieved in each patient (in millimeters) showed that both the models were

statistical signicant (F = 18.6 and P <0.01 for patient satisfaction; F = 11.8 and P <0.01 for patient root coverage). However, in both models, the statistical significance was only reached by the color match (F = 36.9 and P <0.01 for patient satisfaction; F = 22.8 and P <0.01 for patient root coverage) and not by the root coverage (in millimeters) clinically achieved in each patient. No statistically signicant difference between NCCL types and Miller Class gingival recessions was demonstrated in terms of the patient overall
1721

Treatment of Non-Carious Cervical Lesions

Volume 82 Number 12

Table 2.

Mean Facial Keratinized Tissue Increase

Keratinized Tissue Increase (mm) NCCL type Miller Class 1 0.53 0.63 1 0.84 0.92 2 1.55 0.98 II 1.3 0.92 3 0.73 0.77 III 0.55 0.82 4 0.42 0.6 IV 0.3 0.67 5 0.53 0.83

Table 3.

Patient Esthetic Evaluation

NCCL Type (n patients) Parameters 1 (15) 2 (18) 17 1 0 17 1 0 16 2 0 3 (27) 26 1 0 25 2 0 25 2 0 4 (19) 17 2 0 17 2 0 17 2 0 5 (15) 13 2 0 13 2 0 12 3 0

Overall satisfaction VAS 80 15 50 VAS <80 0 VAS <50 0 Color match VAS 80 50 VAS <80 VAS <50 Root coverage VAS 80 50 VAS <80 VAS <50 15 0 0 14 1 0

ence (F = 4.3; P <0.01) among Miller Classes in the periodontist evaluation of root coverage. However, the results from multiple-range tests showed that only Miller Class IV was responsible for the statistical significant difference. No statistically signicant difference among Miller Classes was found in the periodontist evaluation of the color match and tooth emergence prole. DISCUSSION The ideal treatment of a crown-radicular NCCL should consist in a combined restorative/periodontal treatment in which the restorative therapy is completed before mucogingival surgery. This treatment facilitates both procedures: the restorative treatment, which can be performed in an well-isolated operative eld because of the apical dislocation of the soft tissue margin and the periodontal surgery by giving a hard, stable, and convex substrate to the CAF. The improved knowledge of the prognosis of root coverage changed the therapeutic approach of an NCCL associated with gingival recession. From a static approach in which the treatment selection was exclusively based upon the topographical relationship between the NCCL and CEJ (xed referring parameter), it passed to a dynamic approach that takes into consideration the variability in root coverage. The method used in the present study to predetermine the MRC was demonstrated to be reliable in predicting the position of the soft tissue margin after root coverage surgery.7 It allowed for the identication of a scalloped line (MRC) in all teeth affected by gingival recession that could be used as the clinical CEJ (cCEJ)5 for the selection of the therapeutic approach of the NCCL associated with gingival recessions: when the cCEJ was located coronal to the NCCL, a periodontal approach (mucogingival surgery) was indicated; on the contrary, when the cCEJ was located apical to the most coronal extension of the NCCL, a combined restorativeperiodontal approach is recommended. In the latter case, the cCEJ can be used as a guideline for the apical preparation of the composite lling.5

satisfaction, color match, and root coverage VAS scores. Patient esthetic evaluations in different NCCL types are shown in Table 3. Periodontist Evaluation(VAS) Periodontist evaluations of root coverage, color match, and tooth emergence prole were very high in all types of treatment. The results from multiple regression ANOVA relating the periodontist evaluation of root coverage to the color match and root coverage clinically achieved in each patient (in millimeters) showed that the model was highly statistically signicant (F = 51.2; P <0.01). However, statistical signicance was only reached by the color match (F = 99.4; P <0.01) but not by the root coverage clinically achieved in each patient (F = 2.8; not signicant). No statistically signicant difference among NCCL types was found in the periodontist evaluation of root coverage, color match, and tooth emergence prole. Periodontist esthetic evaluations in different NCCL types are shown in Table 4. Results from one-way ANOVA demonstrated a statistically signicant differ1722

J Periodontol December 2011

Zucchelli, Gori, Mele, et al.

Table 4.

Periodontist Esthetic Evaluation

NCCL Type (n patients) Parameters Root coverage VAS 80 50 VAS <80 VAS <50 Color match VAS 80 50 VAS<80 VAS <50 1 (15) 14 1 0 14 1 0 2 (18) 16 2 0 16 2 0 13 5 0 3 (27) 22 5 0 23 4 0 21 6 0 4 (19) 14 5 0 16 3 0 14 5 0 5 (15) 9 6 0 12 3 0 10 5 0

Tooth emergence prole VAS 80 13 50 VAS <80 2 VAS <50 0

In the present study, the predetermination of the MRC resulted in a decision tree for the treatment of an NCCL associated with gingival recessions. An excellent esthetic appearance was achieved in the great majority of patients affected by NCCLs associated with gingival recessions. Although comparative results from non-randomized studies should always be interpreted with caution, the present study data shows that patient satisfaction with esthetics as well as patient and periodontist evaluations in terms of root coverage were very high with no statistically signicant difference among NCCL types, despite the fact that different amounts (in millimeters) of root coverage were achieved. Moreover, no statistically signicant relationships were demonstrated between patient overall satisfaction and patient/periodontist evaluations of root coverage and the amount (in millimeters) of root coverage clinically achieved in each patient. These results are in contrast with the results of another study9 on Miller Class I and II gingival recessions, which demonstrated that the periodontist and patient were well aware of the level of root coverage achieved with the surgery. In that study,9 a statistically signicant correlation was found between patient satisfaction of root coverage (VAS) and the mean percentage of root coverage clinically accomplished in each patient. This discrepancy suggested that when complete root coverage at the level of the anatomic CEJ cannot be accomplished, factors other than root coverage might inuence the objective and subjective esthetic evaluation of the outcome of a surgical procedure. The present study data suggest that it was the presence of a different color (yellow dentin) between the white of the enamel/composite and the pink/red of the soft tissue, more than the apical-coronal level of the soft tis-

sue margin, that was critical in terms of a successful esthetic evaluation of root coverage. In fact, patient satisfaction as well as patient and periodontist evaluations of root coverage were statistically correlated with color-match evaluations (VAS) and not with the amount of root coverage achieved in each patient. Also, the data of the present study show that only Miller Class IV was responsible for the statistical significant difference among Miller Classes in the periodontist evaluation of root coverage supports the proposed treatment approach of an NCCL associated with gingival recessions. The restorativeperiodontal approach did not allow the evaluating periodontist to realize that incomplete root coverage was achieved in the Miller Class III gingival recessions despite the presence of clinical and anatomic conditions limiting the amount of root coverage. The present study also demonstrates that an excellent tooth emergence prole was obtained in the great majority of teeth affected by cervical abrasions with no statistically signicant difference between NCCL types and Miller Class gingival recessions. The objective evaluation of the tooth emergence prole, even if performed by an experienced periodontist, cannot be considered an absolute value of the present study since conclusive and universally accepted parameters to dene a correct emergence prole are not claried. However, the absence of BOP at the facial aspect of all treated sites together with the marked reduction of local plaque scores suggested that the tooth emergence proles accomplished in the present clinical trial were easy to clean by patients. In addition, the increase in KTH might also have contributed to improve the facial plaque control by patients. CONCLUSIONS Within the limits of the present pilot study, it can be suggested that: 1) the predetermination of the MRC can be used for the selection of the treatment approach of an NCCL associated with gingival recessions; 2) the present treatment approach provided a good esthetic appearance and correct emergence prole to the great majority of teeth affected by NCCLs; and 3) the patient overall satisfaction as well as the patient and periodontist evaluations of root coverage were statistically correlated with color-match evaluations (VAS) and not with the amount of root coverage (in millimeters) achieved in each patient. Additional randomized clinical studies are advocated to test the efcacy of the present treatment approach for NCCLs associated with gingival recessions. ACKNOWLEDGMENTS This case study was self-supported by the authors. The authors report no conicts of interest related to this case series.
1723

Treatment of Non-Carious Cervical Lesions

Volume 82 Number 12

REFERENCES
1. Grippo JO, Simring M, Schreiner S. Attrition, abrasion, corrosion and abfraction revisited: A new perspective on tooth surface lesions. J Am Dent Assoc 2004;135: 1109-1118; quiz 1163-1165. 2. Bartlett DW, Shah P. A critical review of non-carious cervical (wear) lesions and the role of abfraction, erosion, and abrasion. J Dent Res 2006;85:306312. 3. Levitch LC, Bader JD, Shugars DA, Heymann HO. Non-carious cervical lesions. J Dent 1994;22:195-207. 4. Hand JS, Hunt RJ, Reinhardt JW. The prevalence and treatment implications of cervical abrasion in the elderly. Gerodontics 1986;2:167-170. 5. Zucchelli G, Testori T, De Sanctis M. Clinical and anatomical factors limiting treatment outcomes of gingival recession: A new method to predetermine the line of root coverage. J Periodontol 2006;77:714721. 6. Miller PD Jr. A classication of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5(2): 8-13. 7. Zucchelli G, Mele M, Stefanini M, et al. Predetermination of root coverage. J Periodontol 2010;81:10191026. 8. Cortellini P, Tonetti M, Baldi C, et al. Does placement of a connective tissue graft improve the outcomes of coronally advanced ap for coverage of single gingival recessions in upper anterior teeth? A multi-centre, randomized, double-blind, clinical trial. J Clin Periodontol 2009;36:68-79.

9. Zucchelli G, Mele M, Mazzotti C, Marzadori M, Montebugnoli L, De Sanctis M. Coronally advanced ap with and without vertical releasing incisions for the treatment of multiple gingival recessions: A comparative controlled randomized clinical trial. J Periodontol 2009;80:1083-1094. 10. OLeary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43:38. 11. Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr HF, Mayer ET. Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. J Periodontol 2001;72:998-1005. 12. Wang HL, Bunyaratavej P, Labadie M, Shyr Y, MacNeil RL. Comparison of 2 clinical techniques for treatment of gingival recession. J Periodontol 2001;72:1301-1311. 13. de Sanctis M, Zucchelli G. Coronally advanced ap: A modied surgical approach for isolated recession-type defects: Three-year results. J Clin Periodontol 2007; 34:262-268. 14. Zucchelli G, Amore C, Sforzal NM, Montebugnoli L, De Sanctis M. Bilaminar techniques for the treatment of recession-type defects. A comparative clinical study. J Clin Periodontol 2003;30:862-870. Correspondence: Prof. Giovanni Zucchelli, Department of Stomatology, University of Bologna, Via S. Vitale 59, 40125 Bologna, Italy. Fax: 39-051-225208; e-mail: giovanni. zucchell@unibo.it Submitted February 7, 2011; accepted for publication March 14, 2011.

1724