LESAO CERVICAL NAO CARIOSA ASSOCIADA A RECESSAO GENGIVAL

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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.
KEY WORDS
Cemento-enamel junction; gingival recession; surgery.
A
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-
effective.
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
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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
evaluations.
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 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 tothe topographic rela-
tionship between the MRC and NCCL. The study
protocol involved a screening appointment to verify
the diagnosis and Miller classification6 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 five
treatment approaches, treatments, the early mainte-
nance phase, and the clinical and esthetic postoper-
ative evaluation 1 year after treatment. An esthetic
postoperative evaluation was made by an indepen-
dent examiner (CM) and by the patient based on a vi-
sual analog scale (VAS) of 100 mm.8,9
Diagnosis of NCCL and Classification 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
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allowed for the realization of the presence of the most
coronal step of the NCCL. The sharpness, depth, and
flat outline of the coronal step of the NCCL distinguished
it from the anatomic CEJ.The examination of the profile
of the target tooth confirmed 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 classification.6
Initial Therapy
After the screening examination, all patients re-
ceived a session of prophylaxis including instruc-
tions 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 abra-
sion/recession defect was not scheduled until the pa-
tient 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 post-
surgery. MM did not perform the surgeries and was un-
aware 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 per-
centage 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 dichoto-
mously (yes/no); 3) distance between the incisal mar-
gin and gingival margin (IM–GM); 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 identified by means of Lugol staining.
Measurements of the IM–GM 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 satis-
faction, color match, and root coverage.9,11,12
Objective Evaluation of Esthetics
The objective evaluation of root coverage (the pres-
ence of exposed root or NCCL), color match between
hard (tooth/composite) and soft tissues, and tooth
emergence profile (capableof protecting the soft tissue
margin and easy to clean by the patient) were scored at
the 1-year post-surgical evaluation visit by another ex-
pert periodontist (CM), who was unaware on the treat-
mentperformed.The periodontist was asked to rate the
root coverage, color match, and tooth emergence pro-
file 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 dis-
tance 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 identifiable, even in a tooth
with an NCCL, by elevating the interdental soft tis-
sues (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 mea-
surements allowed for the identification of two points
that were connected by a scalloped line that repre-
sented the line of root coverage. The MRC was con-
sidered the most apical extension of the line of root
coverage. The predetermination of the MRC was per-
formed by a single, masked examiner (MM) 1 week
before the treatment. The examiner (MM) did not per-
form the treatment.
Determination of Treatment Alternatives
(NCCL types)
The examiner categorized the gingival-NCCL defects
in five types in relation to the position of the MRC with
respect to the NCCL (Fig. 1): type 1; the MRC was lo-
cated >1 mm coronal to the most coronal extension of
the NCCL, type 2; the MRC was located £1 mm coro-
nal 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.
J Periodontol • December 2011 Zucchelli, Gori, Mele, et al.
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deepest portion of the NCCL, and type 5; the MRC
was located at the level or apical to the most apical ex-
tension of the NCCL.
Treatments
Conservative therapy was performed by a single,
masked experienced restorative dentist (GG). Surgical
therapy was performed by a single, masked experi-
enced periodontist (GZ). The adopted surgical tech-
niques consisted of a trapezoidal coronally advanced
flap (CAF) as a root coverage procedure13 or as cov-
ering flap of a subepithelial connective tissue graft in
the bilaminar technique.14 Five different treatment ap-
proaches were adopted according to the NCCL type.
Type 1. NCCL type 1 was a radicular NCCL asso-
ciated with a Miller Class I (Fig. 2) or II gingival reces-
sion. 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 mis-
take (1 mm) in the calculation of the MRC.7 The treat-
ment was exclusively periodontal. The NCCL/gingival
recession was treated by means of a CAF root cover-
age surgical procedure during which the exposed root
surface (including the NCCL) was treated mechani-
cally (with hand and/or rotating instruments) to ob-
tain a hard, smooth, and regularly concave surface
and chemically (24% EDTA for 2 minutes) to elimi-
nate the smear layer. At the end of the surgery, the flap
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 theMRC 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 exclu-
sively 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 (har-
vested from the palate) was positioned inside the root
concavity. The graft thickness filled the abrasion
space and prevented the collapse of the covering soft
tissue flap inside it. The graft, by acting as a filler or
space-keeping inside the concave abrasion area,
provided stability and sustained the covering flap,
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, particu-
larly when the abrasion defect was deep (‡1 mm)
and narrow. A coronal (performed before the restor-
ative 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 flap. The space between the covering flap 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) finished at the level of the MRC and CAF. The shallow space between the covering flapand 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) finished at the level of the MRC and CAF. The
shallow space between the covering flap and the root concavity apical to the MRC was filled 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) finished at the level of the MRC and a repositioned flap or CAF.
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NCCL. The coronal odontoplasty reduced the sharp-
ness and depth of the coronal step of the NCCL and
was extended more and more occlusally with the in-
creasing depth of the hard tissue defect. The grinded
area was restored with a composite filling 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 field by a rubber dam. If and
when the NCCL reached or extended beyond the soft
tissue margin, it was necessary to the elevate the flap
before performing the composite restoration to ex-
pose some root surface apical to NCCL, which was
necessary for isolating the op-
erative field 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 com-
pleted with manual instruments
as far as a correct tooth emer-
gence profile was obtained. The
profile of the composite was
used as a guide for the correct
planning of the root surface.
Once the root odontoplasty
was completed, a pedicle flap
was coronally advanced 1 mm
in excess with respect to the
apical extension of the compos-
ite filling. The conservative fill-
ing facilitated the surgery by
providing a smooth, convex,
and stable substrate for the cor-
onal stabilization of the surgical
flap.
Figure 2.
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
after a flap elevation. C) The flap was coronally advanced and sutured coronal to the CEJ. D) One-year
follow-up after the CAF surgical technique: complete root coverage and a good emergence profile were
obtained. The NCCL defect appeared to be filled by an increased facial soft-tissue thickness.
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 flap inside the NCCL
defect. C) The flap 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 profile were achieved. The NCCL space was filled by the increased thickness of facial gingival tissues.
J Periodontol • December 2011 Zucchelli, Gori, Mele, et al.
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Type 4. NCCL type 4 was a radicular NCCL asso-
ciated with Miller Class III gingival recessions or
a crown-root NCCL associated with Miller Class I
or II gingival recession (Fig. 5) in which the deepest
portion of the NCCL defect was localized at the
level of the anatomic crown and only the apical por-
tion of the NCCL involved the root. In both of
these circumstances, the deepest portion of the
NCCL was not coverable with soft tissue; thus, it
was treated with the composite filling that was
extended up to the MRC. The exposed root surface
apical to the MRC was used for isolating the opera-
tive field by a rubber dam. If this was not feasible,
the rubber dam was applied after elevating
the flap. Mucogingival surgery, consisting of
a CAF technique, was used to cover that por-
tion of the root exposure apical to the compos-
ite filling. The flap was advanced 1 mm coronal
to the apical extension of the composite filling.
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 de-
fect was exclusively restorative. The root cover-
age surgery (if feasible, as with a Miller Class III
gingival recession) might have proceeded inde-
pendently from the restorative therapy, although
it is always recommended that the restoration be
performed first so as not to render the isolation of
the operative field more difficult 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 flap before performing the composite
restoration to expose the root surface apical to
the NCCL, which was necessary for isolating
the operative field with the rubber dam. The sur-
gical flapwaspositioned1mmcoronal to theapi-
cal extension of the composite filling.
Post-Surgical Instructions and Infection
Control
Postoperative pain and edema were controlled
with ibuprofen. Patients received a 600 mg tablet
at the beginning of the surgical procedure and
were instructed to take another tablet 6 hours
later. Subsequent doses were taken onlyif neces-
sary to control pain. Patients were instructed not
to brush in the treated area but to rinse with a
0.12% chlorhexidine solution three times a day
for 1 minute. Fourteen days after the surgical
treatment, sutures were removed. Plaque control
in the surgically treated area was maintained by
chlorhexidine rinsing for an additional 2 weeks.
After this period, patients were again instructed
in mechanical tooth cleaning of the treated tooth using
an ultrasoft toothbrush and a roll technique for 1 month.
During this period, chlorhexidine rinse was used twice
daily. Then, the patient started to use a soft-toothbrush
and to rinse with chlorhexidine once a day. All patients
were recalled for prophylaxis 2 and 4 weeks after suture
removal and, subsequently, once every 2 months until
the final examination (12 months).
Data Analyses
A statistical application software¶ was used for
the statistical analysis. Descriptive statistics were
Figure 4.
NCCL type 3. A) Upper canine with gingival recession and a deep NCCL defect.
The defect involved the crown and root resulting in disappearance of the
anatomic CEJ. The MRC was located within the deepest portion of the abrasion
defect. B) The depth of the NCCL was reduced by means of a coronal odontoplasty,
and the crown emergence profile was restored with a composite filling. C) Flap
elevation. D) The profile of the composite was used as a guide for the correct
planning of the root surface (root odontoplasty). E) The flap was coronally advanced
and secured coronal to the most apical extension of the composite restoration. The
conservative therapy facilitated the surgery by providing a smooth, convex, and
stable substrate for the coronal stabilization of the surgical flap. F) One-year
follow-up: a tooth emergence profile that was easy for the patient to clean and
protecting the soft tissue margin was obtained.
¶ SAS version 6.09, SAS Institute, Cary, NC.
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expressed as means – SDs. General linear models
were fitted, and multiple regression one-way analysis
of variance (ANOVA) for repeated measures with a
split-plot design was used to evaluate the existence
of any significant difference regarding local plaque,
local bleeding, IM–GM distance, KTH, and PD among
NCCL types or Miller Classes, time (1 year versus
baseline), and the interaction between NCCL types
or Miller Classes and time. In case of significance,
the Bonferroni t test was applied as a multiple-com-
parison test.
After controlling for standardized skewness and
standardized kurtosis values for satisfaction, the
color match and root coverage by the patient and
color match, emergence profile, and root coverage
by the periodontist were all within the range expected
for data from a normal distribution; one-way ANOVA
was used to evaluate the presence of any significant
difference among NCCL types and Miller Classes.
The Fisher least-significant difference procedure was
used to discriminate among means.
Multiple linear regression models were fitted to
describe the relationship between patient overall
satisfaction as well as patient and periodontist eval-
uations of root coverage and patient and periodon-
tist evaluations of color match and root coverage
(in millimeters) that were clinically achieved with
the surgery.
RESULTS
A total of 94 gingival recessions
were treated. There were 26 Miller
Class I recessions,20MillerClass
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 associ-
ated with Miller Class I gingival
recessions, and five NCCLs were
associatedwithMillerClass II gin-
gival recessions; 18 (19%) type 2
NCCLs, of which eight were as-
sociated with Miller Class I gin-
gival recessions, and 10 NCCLs
were associated with Miller Class
II gingival recessions; 27 (29%)
type 3 NCCLs, of which four were
associated with Miller Class I
gingival recessions, three were
associatedwithMillerClass II gin-
gival recessions, and 20 NCCLs
were associated with Miller
Class III gingival recessions; 19 (20.2%) type 4
NCCLs, of which four were associated with the Miller
Class I gingival recessions, two were associated with
Miller Class II gingival recessions, and 13 were asso-
ciated with Miller Class III gingival recessions; and 15
(16%) type 5 NCCLs, of which five were associated
with Miller Class III gingival recessions, and 10 were
associated with Miller Class IV gingival recessions.
Oral Hygiene
After the initial oral hygienephaseand atpost-treatment
examinations, all patients showed low frequencies of
plaque-harboring tooth surfaces (full-mouth plaque
score <20%) and bleeding gingival units (full-mouth
bleeding score <15%), indicating a good standard of
supragingival plaque control during the study period.
The results of fitting a general linear statistical
model relating local plaque to NCCL types, time,
and the interaction between NCCL types and time
showed high R2 statistics indicating that the model
as fitted was significant (F = 1.6; P <0.02) and ex-
plained 66% of the variability. A significant relation-
ship was found regarding time-related differences
(F = 26.8l P <0.01), whereas no significant difference
was found concerning NCCL types or the interaction
between NCCL types and time. At baseline, local (fa-
cial) plaque was demonstrated in 26 (28%) treated
sites. Local bleeding was recorded in 22 (23%) sites.
Figure 5.
NCCL type 4. A) Upper canine with a shallow NCCL and deep gingival recession. The NCCL area involved
the crown and root causing the disappearance of the anatomic CEJ. The MRC was located apical to the
deepest portion of the abrasion defect. B) A composite filling restored the deepest portion of the NCCL
defect and was finished at the level of the MRC. A good emergence profile was obtained. C) The portion
of the hard tissue defect apical to the MRC was planned after a flap elevation. D) The profile of the
restoration well supported the CAF, which was sutured coronal to the most apical extension of the
composite filling. E) One-year follow-up after a composite restoration and CAF: a good tooth emergence
profile was obtained. Note that the coronal portion of the abrasion space was filled with composite,
whereas the apical part seemed to be filled by the increased thickness of the facial gingival tissue.
J Periodontol • December 2011 Zucchelli, Gori, Mele, et al.
1719
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 im-
provement in plaque control by patients. No statisti-
cally significant difference was demonstrated in local
plaque at 1 year among NCCL types.
Clinical Changes at 1 Year
IM–GM distance. The results of fitting a general linear
statistical model relating the IM–GM distance to NCCL
types, time, and the interaction between NCCL types
and time showed high R2 statistics, indicating that the
model as fitted was highly significant (F = 22.16;
P <0.01)and explained96%of thevariability.Significant
relationship were found regarding time-related dif-
ferences (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 significant
reduction in the IM–GM distance was demonstrated
when comparing baseline (13.3 – 1.1 mm) and 1-year
(11.2 – 2.3 mm) results. The overall mean root cover-
age amounted to 2.07 – 1.12 mm. The results of
fitting a general linear statistical model relating the
IM–GM distance to Miller Classes, time, and the inter-
action between Miller Classes and time showed high
R2 statistics, indicating that the model as fitted was
highly significant (F = 21.1; P <0.01) and explained
96% of the variability. Significant relationships werefound 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 differ-
ent NCCL types and Miller Classes are shown in Table 1.
KTH. Results of fitting a general linear statistical
model relating KTH to NCCL types, time, and the in-
teraction between NCCL types and time showed high
R2 statistics, indicating that the model as fitted was
highly significant (F = 3.2; P <0.01) and explained
78% of the variability.
Significant relationships were found regarding time-
related 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
significant increase in the KTHwas demonstratedcom-
paring baseline (1.58 – 0.62 mm) with 1-year (2.35 –
0.8 mm) KTH mean values.The overall increase inker-
atinized tissue amounted to 0.76 – 0.86 mm.
The results of fitting 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 fitted was highly significant (F = 2.8; P <0.01)
and explained 75% of the variability. A significant re-
lationship were found regarding time-related differ-
ences (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 fitting a general linear statistical
model relating PD to time, NCCL types, and Miller
Classes did not show any statistically significant dif-
ferences. The 1-year mean facial PD (1.2 – 0.3 mm)
remained shallow with no statistically significant change
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 flap
elevation and rubber-dam application, a composite filling restored the
entire NCCL defect and was finished at the level of the MRC. A good
emergence profile was obtained. C) The composite restoration well
supported the CAF, which was sutured coronal to the most apical
extension of the composite filling. D) One-year follow-up after the
composite restoration and CAF: a good tooth emergence profile was
obtained. Compared to the baseline situation, the length of the clinical
crown was slightly reduced.
Treatment of Non-Carious Cervical Lesions Volume 82 • Number 12
1720
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-regres-
sion ANOVA relating the patient satisfaction and pa-
tient 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 significant (F = 18.6 and P <0.01 for patient
satisfaction; F = 11.8 and P <0.01 for patient root cov-
erage). However, in both models, the statistical signif-
icance 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 significant difference between
NCCL types and Miller Class gingival recessions
was demonstrated in terms of the patient overall
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 1 2 3 4 5
3.06 – 0.79 3.33 – 0.59 1.92 – 0.54 1.47 – 0.51 0.6 – 0.73
Miller Class 1 II III IV
2.69 – 0.67 3.1 – 1.07 1.55 – 0.6 0.4 – 0.69
J Periodontol • December 2011 Zucchelli, Gori, Mele, et al.
1721
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 profile 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 clini-
cally achieved in each patient (in millimeters) showed
that the model was highly statistically significant (F =
51.2; P <0.01). However, statistical significance 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 significant).
No statistically significant difference among NCCL
types was found in the periodontist evaluation of root
coverage, color match, and tooth emergence profile.
Periodontist esthetic evaluations in different NCCL
types are shown in Table 4. Results from one-way AN-
OVA demonstrated a statistically significant differ-
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 signif-
icant difference. No statistically significant difference
among Miller Classes was found in the periodontist
evaluation of the color match and tooth emergence
profile.
DISCUSSION
The ideal treatment of a crown-radicular NCCL
should consist in a combined restorative/periodontal
treatment in which the restorative therapy is com-
pleted before mucogingival surgery. This treatment
facilitates both procedures: the restorative treat-
ment, which can be performed in an well-isolated op-
erative field because of the apical dislocation of the
soft tissue margin and the periodontal surgery by giv-
ing a hard, stable, and convex substrate to the CAF.
The improved knowledge of the prognosis of root cov-
erage changed the therapeutic approach of an NCCL
associated with gingival recession. From a static ap-
proach in which the treatment selection was exclu-
sively based upon the topographical relationship
between the NCCL and CEJ (fixed referring parame-
ter), 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 cover-
age surgery.7 It allowed for the identification of a scal-
loped 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 restorative–periodontal ap-
proach is recommended. In the latter case, the cCEJ
can be used as a guideline for the apical preparation of
the composite filling.5
Table 2.
Mean Facial Keratinized Tissue Increase
Keratinized Tissue Increase (mm)
NCCL type 1 2 3 4 5
0.53 – 0.63 1.55 – 0.98 0.73 – 0.77 0.42 – 0.6 0.53 – 0.83
Miller Class 1 II III IV
0.84 – 0.92 1.3 – 0.92 0.55 – 0.82 0.3 – 0.67
Table 3.
Patient Esthetic Evaluation
NCCL Type (n patients)
Parameters 1 (15) 2 (18) 3 (27) 4 (19) 5 (15)
Overall satisfaction
VAS ‡80 15 17 26 17 13
50£ VAS <80 0 1 1 2 2
VAS <50 0 0 0 0 0
Color match
VAS ‡80 15 17 25 17 13
50£ VAS <80 0 1 2 2 2
VAS <50 0 0 0 0 0
Root coverage
VAS ‡80 14 16 25 17 12
50£ VAS <80 1 2 2 2 3VAS <50 0 0 0 0 0
Treatment of Non-Carious Cervical Lesions Volume 82 • Number 12
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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 ex-
cellent esthetic appearance was achieved in the great
majority of patients affected by NCCLs associated
with gingival recessions. Although comparative re-
sults from non-randomized studies should always be
interpreted with caution, the present study data shows
that patient satisfaction with esthetics as well as pa-
tient and periodontist evaluations in terms of root cov-
erage were very high with no statistically significant
difference among NCCL types, despite the fact that
different amounts (in millimeters) of root coverage
were achieved. Moreover, no statistically significant
relationships were demonstrated between patient
overall satisfaction and patient/periodontist evalua-
tions 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 signi-
ficant correlation was found between patient satisfac-
tion of root coverage (VAS) and the mean percentage
of root coverage clinically accomplished in each pa-
tient. This discrepancy suggested that when complete
root coverage at the level of the anatomic CEJ cannot
be accomplished, factors other than root coverage
might influence 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 tis-
sue, 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 evalua-
tions 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 signif-
icant difference among Miller Classes in the periodon-
tist evaluation of root coverage supports the proposed
treatment approach of an NCCL associated with gin-
gival recessions. The restorative–periodontal ap-
proach 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 excel-
lent tooth emergence profile was obtained in the great
majority of teeth affected by cervical abrasions with
no statistically significant difference between NCCL
types and Miller Class gingival recessions. The objec-
tive evaluation of the tooth emergence profile, even
if performed by an experienced periodontist, cannot
be considered an absolute value of the present study
since conclusive and universally accepted parame-
ters to define a correct emergence profile are not clar-
ified. 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 emer-
gence profiles accomplished in the present clinical
trial were easy to clean by patients. In addition, the in-
crease in KTH might also have contributed to improve
the facial plaque control by patients.
CONCLUSIONS
Within the limitsof the presentpilot study, it canbesug-
gested 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 pres-
ent treatment approach provided a good esthetic ap-
pearance and correct emergence profile to the great
majority of teeth affected by NCCLs; and 3) the patient
overall satisfaction as well as the patient and periodon-
tist evaluations of root coverage were statistically cor-
related with color-match evaluations (VAS) and not
with the amount of root coverage (in millimeters)
achieved in each patient. Additional randomized clini-
cal studies are advocated to test the efficacy 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 conflicts of interest related to
this case series.
Table 4.
Periodontist Esthetic Evaluation
NCCL Type (n patients)
Parameters 1 (15) 2 (18) 3 (27) 4 (19) 5 (15)
Root coverage
VAS ‡80 14 16 22 14 9
50£ VAS <80 1 2 5 5 6
VAS <50 0 0 0 0 0
Color match
VAS ‡80 14 16 23 16 12
50£ VAS<80 1 2 4 3 3
VAS <50 0 0 0 0 0
Tooth emergence profile
VAS ‡80 13 13 21 14 10
50£ VAS <80 2 5 6 5 5
VAS <50 0 0 0 0 0
J Periodontol • December 2011 Zucchelli, Gori, Mele, et al.
1723
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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.
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