Managing Multiple Recession Defects Associated With Noncarious Cervical Lesions

Gingival recession defects (GRD) are highly prevalent mucogingival conditions defined as the apical shift of the gingival margin, which exposes part of the root surface to the oral cavity.¹ Approximately 50% of GRD are associated with carious or noncarious cervical lesions (NCCLs),² and their etiology is likely multifactorial.^1,3-5 Patients seek periodontal treatment of GRD for esthetic reasons or to prevent further progression of gingival recession and the resultant cervical abrasion, which may lead to increased sensitivity from exposed root structure. NCCLs are present in 50% of sites with gingival recession, resulting in a decreased probability of achieving complete root coverage.^6–9

Restoring NCCLs can be a significant challenge. Although NCCL restorations are common in clinical settings, they are less durable, come with a high index of loss of retention, marginal excess, and secondary caries.¹⁰ The restorative treatment of cervical lesions, both carious and noncarious, with composite restorations are often compromised by moisture, contamination, and improper access to the subgingival margins due to the presence of sclerotic dentin, which has less bonding tensile strength than the normal dentin.^11–13

In addition, dentinal bonding problems may lead to marginal leakage and failure of the restoration. These faulty restorations may also compromise periodontal health. Poalantino et al¹⁴ reported that cervical composite restorations negatively affect subgingival plaque  because they increase the total Gram-negative anaerobic bacterial count and decrease Gram-positive aerobic bacteria.

In order to improve outcomes, a combined periodontal and restorative treatment has been proposed to treat recession defects associated with NCCLs. Previously, a decision-making process for treating GRD associated with NCCLs was proposed.^15–17 The treatment protocol was based on the maximum root coverage achievable by mucogingival surgery and the extent of the NCCL involving the root, crown, or both. The authors presented treatment protocols incorporating two essential factors: predetermination of whether the NCCL can be partially/completely covered by soft tissue and potential collapse of the gingival margin into the NCCL concavity. In order to avoid such a collapse, the authors suggested the addition of the connective tissue graft or acellular dermal matrix (ADM) to act as a biological filler and prevent the gingival margin collapse during healing.^15–17   Therefore, in the treatment planning of such combined defects, the location and depth of the NCCL must be considered.

Different materials have been proposed for the treatment of the NCCL.¹⁸ Lucchesi et al¹⁹ compared two surgical-restorative approaches to treat these combined defects. A coronally advanced flap was associated with either a microfilled resin composite or resin-modified glass ionomer, restoring the entire NCCL. These treatments were compared with coronally advanced flap applied on an intact tooth surface, where gingival recession was not associated with the NCCL. The two groups that received restorations achieved similar defect coverage: 74.18 ± 15.0% for the resin composite group and 71.99 ± 18.7% for the resin-modified glass ionomer group. In addition, despite being placed subgingivally, the two materials did not present any significant difference in tissue inflammation, both showing only a few cases of bleeding on probing after 6 months.

Case #1

In 2012, a systemically healthy, 43-year-old, nonsmoking man was referred for periodontal evaluation with a chief complaint of poor esthetics and root hypersensitivity from teeth #11, 12, 13, and 14. Clinical examination revealed the presence of multiple adjacent GRDs of the involved sites associated with NCCL (Figure 1 above).

The diagnosis was Miller Class I recession defect (RT1), undetectable cementoenamel junction (CEJ) (B), presence of a root step on #11 (+), and >  2 mm of keratinized tissue apical to the recessions.^2,20,21 The risks and benefits of perio-plastic surgery were discussed with the patient, who expressed the desire to proceed.

Before any restorative or surgical procedure was started, the patient underwent oral hygiene instructions, supragingival scaling, and prophylaxis. The following parameters were assessed at the beginning of the treatment, prior to the periodontal surgery: recession depth, recession width, probing depth, clinical attachment level, tissue thickness via sulcular probing, and keratinized tissue width.

Restorative Procedure

NCCL restorations were performed in a single appointment immediately prior to surgical treatment. The restorative procedure was intended to reconstruct the anatomic crown destroyed by the NCCL progression and the root surface to the level of maximum root coverage. The same experienced operators performed all the restorative and periodontal procedures. Before the restorative procedure, the maximum root coverage that could be achieved by periodontal surgery was determined using the 3 mm rule.^15,22 This states the soft tissue grafting can bring the facial gingival margin to within 3 mm of the papillae tip, providing that the papillae have a width of at least 3 mm at its base. The papillae base is located at a point 3 mm apical to the papillae tip.

After local anesthesia, the demineralized/hypermineralized exposed dentin was removed. The area was etched with 37% phosphoric acid for 30 seconds and then washed with a water jet. A multistep adhesive system was used following the manufacturer’s instructions. Flowable composite resin was applied in the center/deepest portion of the NCCL, avoiding the marginal area of the cavity preparation. A nanofilled composite resin was used after that to complete the restoration. Finishing and polishing were performed with extra-fine diamond burs and soft silicon rubber wheels, followed by composite polishing cups.

Surgical Protocol

After confirming local anesthesia, hand and rotary instruments were used to ensure a smooth root surface. After thorough debridement and smoothing, the exposed root surface was treated with 17% ethylenediaminetetraacetic acid (EDTA) applied for 1 minute with a cotton tip applicator to remove the smear layer and expose the dentinal collagen fibers/tubules.

The site preparation started with an incision made with an end-cutting intracellular knife, followed by a supra-periosteal blunt dissection extending to the mucogingival junction using a periosteal elevator. Then, a partial thickness dissection with a modified Orban knife was continued apically, approximately 10 mm from the gingival margin, to allow for a passive advancement of a pouch. The pouch was extended laterally to include the papillae of the adjacent teeth.

The allograft was rehydrated ac­cording to the manufacturer’s instructions for a minimum of 10 minutes. The tension-free pouch was coronally positioned to cover the ADM completely. Double sling sutures were used around each tooth to secure the graft without the placement of interproximal composite and position the graft and the pouch coronally (Figure 2).

Analgesics were prescribed to control postoperative discomfort (ibu­profen 800 mg q6h for one week, ace­ta­minophen #3 q6h as needed). To prevent any infection, azithro­mycin (500 mg) was prescribed; two tablets were taken on the day of surgery, followed by one tablet per day for 3 days.

To control the swelling, dexamethasone was prescribed, 8 mg 2 hours before surgery, 6 mg on the second day, 4 mg on the third day, and 2 mg on the fourth day. No brushing or flossing at the surgical site was performed for 3 weeks. Chlorhexidine gluconate (0.12%) mouthrinse twice daily was prescribed for 3 weeks after the surgery to control plaque buildup.

The patient was seen postoperatively at 3 weeks when the sutures were removed. Oral hygiene instructions were given and prophylaxis was performed at each follow-up visit if indicated (ie, visible plaque present). The patient was seen 3 months and 6 months postsurgery to monitor healing (Figure 3).

Case #2

A 39-year-old nonsmoking woman with no significant health issues presented to the clinic for alternative treatment options regarding her generalized gingival recession associated with the presence of NCCLs. The clinical oral examination re­vealed the following: NCCLs presented in the maxillary left quadrant involving the root surfaces on teeth #10, 11, and 12. All the teeth mentioned had gingival recession (RT1). A deep step > 0.5 mm was present on teeth #11 and 12 (Figure 4). The case was treated in the same protocol described in case #1 (Figures 5 and 6). Complete root coverage was achieved at 3 months and was maintained for 1 year (Figure 7).

Case #3

A 39-year-old man presented with complaints of long teeth and hypersensitivity in the maxillary right area. Clinical evaluation revealed the presence of NCCLs without enamel involvement associated with gingival recession on tooth #6 and an NCCL with enamel involvement associated with an RT1 on tooth 5 (Figure 8).

After the patient consented to treatment, the restorative and periodontal procedures were performed as described in case #1 (Figures 9 and 10). The patient returned for a routine appointment 10 years post-treatment. Clinical examination revealed complete root coverage on the treated teeth, and the patient reported no sensitivity (Figure 11).

Discussion

In this case series, multiple GRD with NCCLs were treated with modified coronally advanced tunnel (MCAT) technique, ADM, and composite restorations, resulting in complete root coverage. Studies have shown that ADM provides a suitable alternative for the autogenous graft and, in selected cases, leads to similar results.²³ Literature published on the efficacy of ADM in the absence of cervical lesions or previous restorations suggests that adding ADM improves the short-term outcome of the flap-alone counterparts.^24–27

The use of ADM is technique sensitive compared to connective tissue grafting. Because of the nonautogenous source, the supply is unlimited and generalized recession cases can be potentially treated in a single appointment. ADM has a relatively uniform thickness and therefore can be used as a filler to stabilize a coronally advanced flap or a MCAT technique on the root surface, preventing the flap’s collapse. It increases gingival thickness, and the thick, dense connective tissue that results creates a stable marginal tissue, preventing the recurrence of a gingival recession.

The increase in tissue thickness is one of the advantages attributed to ADM compared to a flap alone.^27–29 ADM is a scaffold that promotes cellular migration and revascularization from the host tissue.³⁰ The increase in gingival thickness, ranging from 0.51 mm to ≥1.2 mm, makes the gingival margin more stable and less prone to relapse in the long‐term, as noted in the present case report, as well as in the periodontal literature.^28,31,32

Conclusion

The restored NCCL was successfully treated with ADM and MCAT in this case series. These results confirm that ADM presented stable outcomes in the presence of composite restorations for up to 10 years. Furthermore, the subgingival placement of the restoration does not influence the percentage of root coverage and does not affect the periodontal parameters of the treated teeth.

Despite the subgingival location of the apical margin of the restored NCCLs, an excellent esthetic outcome with healthy gingiva without inflammation, redness, or bleeding on probing was observed over time. These findings agree with previous reports.^33–35 This type of approach should be considered a treatment option for the recession defects associated with NCCLs.

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From Decisions in Dentistry. January/February 2024; 10(1):36-41