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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 reli-
able in predicting the position of the soft tissue margin after
root coverage surgery. The aim of the present study is to sug-
gest a decision-making process for treating non-carious cervi-
cal lesions (NCCLs) associated with gingival recessions based
upon the topographic relationship between the MRC and
NCCL and to assess patient and independent-periodontist es-
thetic evaluations.
Methods: Five treatments were performed in 94 patients
with NCCLs associated with a single gingival recession: 1)
coronally advanced flap (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 evalu-
ation of root coverage and the periodontist evaluation of root
coverage were statistically correlated with color-match evalu-
ations and not with the amount of root coverage clinically
achieved in each patient.
Conclusion: The proposed approaches provided good
esthetic appearance and correct emergence profile for the
great majority of NCCLs associated with gingival recessions.
J Periodontol 2011;82:1713-1724.
Cemento-enamel junction; gingival recession; surgery.
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 Al-
though 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 corro-
sion, 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 hyper-
sensitivity, 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 difficult/in-
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 commonlyassociated
withgingival recession.AnNCCLinvolving
* 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.
doi: 10.1902/jop.2011.110080
J Periodontol • December 2011
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 mu-
cogingival surgery. The true clinical context is more
complexand, frequently, theNCCL involvesboth the
crown and root, causing the disappearance of the
cemento-enamel junction (CEJ), which anatomi-
cally separates the crown from the root.5 Thereafter,
the main referring parameter for the selection of the
therapeutic approach is no longer available. Fur-
thermore, 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 sup-
port5 (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 proce-
dures: the restoration that can be easily performed
and finished in an isolated (with rubber dam) field
without interference of the soft tissues, and the
root-coverage surgery is facilitated by the recon-
struction of the clinical crown emergence profile that
provides a stable, smooth, and convex substrate for
the surgical flap.
The main clinical concern is when to finish the
composite restoration. Theoretically, the composite
filling should be placed when gingival tissues are stable
after the healing process of the mucogingival root cov-
erage procedure. This position was described as the
maximum root coverage level (MRC).7 This level is de-
fined as a line (line of root coverage) that should coin-
cide 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 inter-
dental 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 deci-
sion-making process for treating NCCLs associated
with gingival recessions based upon the topographic
relationship between the MRC and NCCL and to as-
sess patient and independent-periodontist esthetic
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 con-
secutive basis among individuals referred to the
School of Dentistry, University of Bologna, in the pe-
riod 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 commit-
tee of Bologna University.
All participants met the following study inclusion cri-
teria: 1) aged >18 years; 2) periodontally and system-
ically healthy; 3) NCCL associated with a single Miller
Class I, II, III, or IV gingival recession (rotated, malpo-
sitioned, extruded teeth with or without occlusal wear
and teeth with some loss of papillae height5 were in-
cluded 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 inwhich itwasnot possible topredetermine
the MRC (the absence of a contact point in the tooth
with gingival recession and in the homologous contra-
lateral 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 gin-
gival recessions according to