Case Series

Non-Carious Cervical LesionsAssociated With Gingival Recessions:A Decision-Making ProcessGiovanni Zucchelli,* Guido Gori,† Monica Mele,* Martina Stefanini,* Claudio Mazzotti,*Matteo Marzadori,* Lucio Montebugnoli,‡ and Massimo De Sanctis§

Background: A method to predetermine the maximum rootcoverage level (MRC) was recently demonstrated to be reli-able in predicting the position of the soft tissue margin afterroot 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 basedupon the topographic relationship between the MRC andNCCL and to assess patient and independent-periodontist es-thetic evaluations.

Methods: Five treatments were performed in 94 patientswith NCCLs associated with a single gingival recession: 1)coronally advanced flap (CAF); 2) bilaminar procedure; 3)coronal odontoplasty plus restoration plus root odontoplastyplus CAF; 4) restoration plus CAF; and 5) restorative therapy.Clinical and esthetic evaluations made by the patient and anindependent periodontist were done 1 year after treatments.

Results: The satisfaction of the patient and periodontistwith esthetics was very high in all NCCL treatments and MillerClass gingival recessions. The patient satisfaction and evalu-ation of root coverage and the periodontist evaluation of rootcoverage were statistically correlated with color-match evalu-ations and not with the amount of root coverage clinicallyachieved in each patient.

Conclusion: The proposed approaches provided goodesthetic appearance and correct emergence profile for thegreat majority of NCCLs associated with gingival recessions.J Periodontol 2011;82:1713-1724.

KEY WORDS

Cemento-enamel junction; gingival recession; surgery.

Anon-carious cervical lesion (NCCL)is described as the wear of thetooth substance at the level of the

gingival one-third of the tooth due toreasons other than dental caries.1,2 Al-though an abrasion, due to mechanicalforces,3 plays an important role in thedevelopment of NCCLs, it is not the solecause, and it is generally accepted thatthe 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 anNCCL are: 1) esthetics, especially whenthe lesion is pigmented and/or associatedwith gingival recession; 2) dentin hyper-sensitivity, which may be the cause ofdiscomfort/pain or faulty plaque controlfor the patient; 3) caries/demineralizationwith or without dentin hypersensitivity;and 4) bacterial plaque accumulationdue to the shape and/or depth of abrasionthat make oral health care difficult/in-effective.

From a topographic standpoint, anNCCL can involve only the crown of thetooth (enamel and/or coronal dentin) oronly the root surface (cementum and/orroot dentin), or it can occupy both thecrown and exposed root. When the NCCLinvolves the root it is commonlyassociatedwithgingival 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 betreated with restorative therapy, whereas an NCCLlimited to the root surface should be treated with mu-cogingival surgery. The true clinical context is morecomplexand, frequently, theNCCL involvesboth thecrown and root, causing the disappearance of thecemento-enamel junction (CEJ), which anatomi-cally separates the crown from the root.5 Thereafter,the main referring parameter for the selection of thetherapeutic approach is no longer available. Fur-thermore, the anatomic distinction between crownand root does not always correspond to the clinicalone and the entire exposed root surface is coveredwith soft tissues; this is the case with Miller Class6

III and IV gingival recessions. Furthermore, differentlocal conditions at a tooth with gingival recessionmay limit the amount of root coverage, even in theabsence of the loss of interdental periodontal sup-port5 (i.e., the loss of the tip of the papilla or tips ofpapillae, tooth rotation, and tooth extrusion withor without occlusal wear). The ideal treatment of acrown-radicular NCCL should consist of a combinedrestorative/periodontal treatment. Completing therestorative therapy before mucogingival surgeryleads to various clinical advantages for both proce-dures: the restoration that can be easily performedand finished in an isolated (with rubber dam) fieldwithout interference of the soft tissues, and theroot-coverage surgery is facilitated by the recon-struction of the clinical crown emergence profile thatprovides a stable, smooth, and convex substrate forthe surgical flap.

The main clinical concern is when to finish thecomposite restoration. Theoretically, the compositefilling should be placed when gingival tissues are stableafter the healing process of the mucogingival root cov-erage procedure. This position was described as themaximum 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 clinicallydetectable on the tooth with Miller Class I or II gingivalrecession or would be more apical than the anatomicCEJ when the ideal anatomic conditions to obtaincomplete root coverage were not fully represented(i.e., a Miller Class III gingival recession).5

A method to predetermine the MRC based on thecalculation of the ideal height of the anatomic inter-dental papilla was demonstrated to be reliable inpredicting the position of the soft tissue margin 3months after root coverage surgery.7 The aim of thepresent pilot, case series study is to suggest a deci-sion-making process for treating NCCLs associatedwith gingival recessions based upon the topographicrelationship between the MRC and NCCL and to as-sess patient and independent-periodontist estheticevaluations.

MATERIALS AND METHODS

Ninety-four patients (45 males and 49 females; agerange: 20 to 48 years; mean age: 34.6 – 9 years) wereenrolled in the study. Patients were selected on a con-secutive basis among individuals referred to theSchool of Dentistry, University of Bologna, in the pe-riod between September 2007 and April 2008. Thestudy protocol, questionnaires, and informed writtenconsent is in full accordance with the ethical principlesof the Declaration of Helsinki of 1975, as revised in2000, were approved by an institutional review boardand 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 MillerClass I, II, III, or IV gingival recession (rotated, malpo-sitioned, extruded teeth with or without occlusal wearand teeth with some loss of papillae height5 were in-cluded in Miller Class III); 4) no contraindications forperiodontal surgery; 5) not taking medications knownto interfere with periodontal tissue health or healing;and 6) no previous periodontal surgery at involvedsites.Teeth inwhich itwasnot possible topredeterminethe MRC (the absence of a contact point in the toothwith gingival recession and in the homologous contra-lateral one) or that had prosthetic crowns or compositerestorations extending on the facial root surface wereexcluded from the study. Patients who smoked >10cigarettes a day were also excluded. Recession defectsassociated with evidence of pulpal pathology were notincluded, and molar teeth were excluded.

Study DesignThis was a pilot, case-series study selecting differenttreatment approaches for NCCL associated with gin-gival recessions according to the topographic rela-tionship between the MRC and NCCL. The studyprotocol involved a screening appointment to verifythe diagnosis and Miller classification6 of gingivalrecession and eligibility (presence of an NCCL)followed by initial therapy to establish optimalplaque control and gingival health conditions, thepredetermination of MRC, the selection of one of fivetreatment approaches, treatments, the early mainte-nance phase, and the clinical and esthetic postoper-ative evaluation 1 year after treatment. An estheticpostoperative 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 ofGingival RecessionsNCCL was considered a loss of hard tissue localized inthe gingival one-third of the tooth.1,2 A diagnosis of anNCCL was made by using a periodontal probe that

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allowed for the realization of the presence of the mostcoronal step of the NCCL. The sharpness, depth, andflat outline of the coronal step of the NCCL distinguishedit from the anatomic CEJ.The examination of the profileof the target tooth confirmed the diagnosis of an NCCLand easily differentiated the coronal step of the NCCLfrom the CEJ. Gingival recessions were categorized intofour classes according to the Miller classification.6

Initial TherapyAfter the screening examination, all patients re-ceived a session of prophylaxis including instruc-tions in proper oral hygiene measures, scaling, andprofessional tooth cleaning with the use of a rubbercup and a low-abrasive polishing paste. A coronallydirected roll technique was prescribed for teeth withrecession defects to minimize toothbrushing traumato the gingival margin. The treatment of the abra-sion/recession defect was not scheduled until the pa-tient was able to demonstrate an adequate standardof supragingival plaque control.

Clinical MeasurementsAll 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 intraexaminererror (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 Bleedingon probing (BOP) was assessed dichotomously ata force of 0.3 N with a manual pressure-sensitiveprobe.i The full-mouth bleeding score was recordedas the percentage of total surfaces (four aspects pertooth) that revealed the presence of BOP.

The following clinical measurements were taken 1week before the surgery and at the 1-year follow-upat 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 bottomof gingival sulcus; and 5) height of keratinized tissue(KTH), which was the distance between the gingivalmargin and mucogingival junction. The mucogingivaljunction was identified by means of Lugol staining.Measurements of the IM–GM distance, PD, and KTHwere performed by using a manual probe and wererounded up to the nearest millimeter.

Patient Esthetic EvaluationPatient satisfaction with esthetics was evaluated atthe 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 EstheticsThe objective evaluation of root coverage (the pres-ence of exposed root or NCCL), color match betweenhard (tooth/composite) and soft tissues, and toothemergence profile (capableof protecting the soft tissuemargin and easy to clean by the patient) were scored atthe 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 theroot 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 MRCThe method used to predetermine the MRC in teethwith NCCL associated with gingival recessions wasrecently published by our research group.7 Themethod was based on the calculation of the idealheight 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 crossedthe 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 toothwith an NCCL, by elevating the interdental soft tis-sues (with a probe or small spatula) and searchingfor the interdental CEJ. Once the ideal papilla wasmeasured, this dimension was replaced apicallystarting from the tips of the mesial and distal papillaeof the tooth with the recession defect. The horizontalprojections on the recession margin of these mea-surements allowed for the identification of two pointsthat 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 rootcoverage. The predetermination of the MRC was per-formed by a single, masked examiner (MM) 1 weekbefore the treatment. The examiner (MM) did not per-form the treatment.

Determination of Treatment Alternatives(NCCL types)The examiner categorized the gingival-NCCL defectsin five types in relation to the position of the MRC withrespect to the NCCL (Fig. 1): type 1; the MRC was lo-cated >1 mm coronal to the most coronal extension ofthe 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 theNCCL, type 4; the MRC was located apical to the

i PCP UNC-15 probe tip, Hu-Friedy, Chicago, IL; equipped with a Brodonticspring device, Dentramar, Waalwijk, The Netherlands.

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deepest portion of the NCCL, and type 5; the MRCwas located at the level or apical to the most apical ex-tension of the NCCL.

TreatmentsConservative therapy was performed by a single,masked experienced restorative dentist (GG). Surgicaltherapy was performed by a single, masked experi-enced periodontist (GZ). The adopted surgical tech-niques consisted of a trapezoidal coronally advancedflap (CAF) as a root coverage procedure13 or as cov-ering flap of a subepithelial connective tissue graft inthe 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 toothsurface comprised between the MRC and the coronalstep 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/gingivalrecession was treated by means of a CAF root cover-age surgical procedure during which the exposed rootsurface (including the NCCL) was treated mechani-cally (with hand and/or rotating instruments) to ob-tain a hard, smooth, and regularly concave surfaceand chemically (24% EDTA for 2 minutes) to elimi-nate the smear layer. At the end of the surgery, the flapwas coronally advanced 1 mm in excess with respectto the MRC.

Type 2. NCCL type 2 was also a radicular NCCLassociated with a Miller Class I or II (Fig. 3) gingivalrecession, but in this case, there was not enoughspace between the MRC and coronal step of theNCCL to compensate for errors in the calculationof the MRC and/or the post-surgical soft tissueshrinkage. Therefore, there was a risk of soft tissuescollapse into the abrasion space. In this case too, thetreatment of the NCCL/gingival recession was exclu-sively periodontal. The NCCL was mechanically andchemically treated during mucogingival surgery, butin this case, the root coverage procedure consisted ina bilaminar technique (i.e., a connective tissue graftcovered by a CAF). The connective tissue graft (har-vested from the palate) was positioned inside the rootconcavity. The graft thickness filled the abrasionspace and prevented the collapse of the covering softtissue flap inside it. The graft, by acting as a filler orspace-keeping inside the concave abrasion area,provided stability and sustained the covering flap,which was coronally advanced 1 mm in excess withrespect to the MRC.

Type 3. NCCL type 3 was a crown-radicular NCCLassociated with a Miller Class I (Fig. 4), II, or III gingivalrecession. 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 duringthe mucogingival surgery) odontoplasty was doneto 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 withgingival recession. B) NCCL type 1: the MRC (arrow) was located >1mm coronal to the coronal step of the NCCL. The treatment consisted of a coronallyadvanced pedicle flap. The space between the covering flap and the root concavity was occupied by blood coagulum (red area). C) NCCL type 2: theMRC (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: theMRC (arrow) was located in the deepest portion of the abrasion defect. The treatment consisted of a coronal and radicular odontoplasty compositerestoration (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, wasoccupied 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 amild 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. Theshallow 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 (blackarrow) 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 consistedof 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 andwas extended more and more occlusally with the in-creasing depth of the hard tissue defect. The grindedarea was restored with a composite filling that wasextended up to the MRC. The coronal odontoplastymade 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 usedfor isolating the operative field by a rubber dam. If andwhen the NCCL reached or extended beyond the softtissue margin, it was necessary to the elevate the flapbefore performing the composite restoration to ex-pose some root surface apical to NCCL, which was

necessary for isolating the op-erative field with the rubberdam. The root odontoplastywas performed during surgeryto further reduce the depth ofthe NCCL. It was performedwith rotating burs and was com-pleted with manual instrumentsas far as a correct tooth emer-gence profile was obtained. Theprofile of the composite wasused as a guide for the correctplanning of the root surface.Once the root odontoplastywas completed, a pedicle flapwas coronally advanced 1 mmin excess with respect to theapical extension of the compos-ite filling. The conservative fill-ing facilitated the surgery byproviding a smooth, convex,and stable substrate for the cor-onal stabilization of the surgicalflap.

Figure 2.NCCL type 1. A) Canine with gingival recession and a shallow radicular NCCL defect. The hard tissue defectwas completely coverable with soft tissues. B) Root surface and NCCL area were mechanically treatedafter a flap elevation. C) The flap was coronally advanced and sutured coronal to the CEJ. D) One-yearfollow-up after the CAF surgical technique: complete root coverage and a good emergence profile wereobtained. 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 waspositioned and sutured within the NCCL space. The graft acted as space-maintaining material preventing the collapse of the covering flap inside the NCCLdefect. C) The flap was coronally advanced and sutured coronal to the CEJ. D) One-year follow-up after a bilaminar technique: complete root coverageand a good emergence profile were achieved. The NCCL space was filled by the increased thickness of facial gingival tissues.

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Type 4. NCCL type 4 was a radicular NCCL asso-ciated with Miller Class III gingival recessions ora crown-root NCCL associated with Miller Class Ior II gingival recession (Fig. 5) in which the deepestportion of the NCCL defect was localized at thelevel of the anatomic crown and only the apical por-tion of the NCCL involved the root. In both ofthese circumstances, the deepest portion of theNCCL was not coverable with soft tissue; thus, itwas treated with the composite filling that wasextended up to the MRC. The exposed root surfaceapical 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 elevatingthe flap. Mucogingival surgery, consisting ofa 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 coronalto the apical extension of the composite filling.

Type 5. NCCL type 5 was a radicular NCCLassociated with a Miller Class III and IV gingivalrecession (Fig. 6). The NCCL was located on thatportion of the root surface that was not coverablewith soft tissues. Therefore, treatment of the de-fect was exclusively restorative. The root cover-age surgery (if feasible, as with a Miller Class IIIgingival recession) might have proceeded inde-pendently from the restorative therapy, althoughit is always recommended that the restoration beperformed first so as not to render the isolation ofthe operative field more difficult due to the morecoronal location of the soft tissues. If and whenthe NCCL reached or extended beyond the softtissue margin (Fig. 6), it was necessary to theelevate the flap before performing the compositerestoration to expose the root surface apical tothe NCCL, which was necessary for isolatingthe operative field with the rubber dam. The sur-gical flapwaspositioned1mmcoronal to theapi-cal extension of the composite filling.

Post-Surgical Instructions and InfectionControlPostoperative pain and edema were controlledwith ibuprofen. Patients received a 600 mg tabletat the beginning of the surgical procedure andwere instructed to take another tablet 6 hourslater. Subsequent doses were taken only if neces-sary to control pain. Patients were instructed notto brush in the treated area but to rinse with a0.12% chlorhexidine solution three times a dayfor 1 minute. Fourteen days after the surgicaltreatment, sutures were removed. Plaque controlin the surgically treated area was maintained bychlorhexidine rinsing for an additional 2 weeks.After this period, patients were again instructed

in mechanical tooth cleaning of the treated tooth usingan ultrasoft toothbrush and a roll technique for 1 month.During this period, chlorhexidine rinse was used twicedaily. Then, the patient started to use a soft-toothbrushand to rinse with chlorhexidine once a day. All patientswere recalled for prophylaxis 2 and 4 weeks after sutureremoval and, subsequently, once every 2 months untilthe final examination (12 months).

Data AnalysesA statistical application software¶ was used forthe 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 theanatomic CEJ. The MRC was located within the deepest portion of the abrasiondefect. 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) Flapelevation. D) The profile of the composite was used as a guide for the correctplanning of the root surface (root odontoplasty). E) The flap was coronally advancedand secured coronal to the most apical extension of the composite restoration. Theconservative therapy facilitated the surgery by providing a smooth, convex, andstable substrate for the coronal stabilization of the surgical flap. F) One-yearfollow-up: a tooth emergence profile that was easy for the patient to clean andprotecting the soft tissue margin was obtained.

¶ SAS version 6.09, SAS Institute, Cary, NC.

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expressed as means – SDs. General linear modelswere fitted, and multiple regression one-way analysisof variance (ANOVA) for repeated measures with asplit-plot design was used to evaluate the existenceof any significant difference regarding local plaque,local bleeding, IM–GM distance, KTH, and PD amongNCCL types or Miller Classes, time (1 year versusbaseline), and the interaction between NCCL typesor 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 andstandardized kurtosis values for satisfaction, thecolor match and root coverage by the patient andcolor match, emergence profile, and root coverageby the periodontist were all within the range expectedfor data from a normal distribution; one-way ANOVAwas used to evaluate the presence of any significantdifference among NCCL types and Miller Classes.The Fisher least-significant difference procedure wasused to discriminate among means.

Multiple linear regression models were fitted todescribe the relationship between patient overallsatisfaction 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 withthe surgery.

RESULTS

A total of 94 gingival recessionswere treated. There were 26 MillerClass I recessions,20MillerClassII recessions, 38 Miller Class IIIrecessions (including rotated ormalpositioned and extrudedteeth with or without an occlusalabrasion and teeth with someloss of papillae height), and 10Miller Class IV recessions.

There were 15 (16%) type 1NCCLs, of which 10 were associ-ated with Miller Class I gingivalrecessions, and five NCCLs wereassociatedwithMillerClass II gin-gival recessions; 18 (19%) type 2NCCLs, of which eight were as-sociated with Miller Class I gin-gival recessions, and 10 NCCLswere associated with Miller ClassII gingival recessions; 27 (29%)type 3 NCCLs, of which four wereassociated with Miller Class Igingival recessions, three wereassociatedwithMillerClass II gin-gival recessions, and 20 NCCLswere associated with Miller

Class III gingival recessions; 19 (20.2%) type 4NCCLs, of which four were associated with the MillerClass I gingival recessions, two were associated withMiller 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 associatedwith Miller Class III gingival recessions, and 10 wereassociated with Miller Class IV gingival recessions.

Oral HygieneAfter the initial oral hygienephaseand atpost-treatmentexaminations, all patients showed low frequencies ofplaque-harboring tooth surfaces (full-mouth plaquescore <20%) and bleeding gingival units (full-mouthbleeding score <15%), indicating a good standard ofsupragingival plaque control during the study period.

The results of fitting a general linear statisticalmodel relating local plaque to NCCL types, time,and the interaction between NCCL types and timeshowed high R2 statistics indicating that the modelas 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 differencewas found concerning NCCL types or the interactionbetween NCCL types and time. At baseline, local (fa-cial) plaque was demonstrated in 26 (28%) treatedsites. 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 involvedthe crown and root causing the disappearance of the anatomic CEJ. The MRC was located apical to thedeepest portion of the abrasion defect. B) A composite filling restored the deepest portion of the NCCLdefect and was finished at the level of the MRC. A good emergence profile was obtained. C) The portionof the hard tissue defect apical to the MRC was planned after a flap elevation. D) The profile of therestoration well supported the CAF, which was sutured coronal to the most apical extension of thecomposite filling. E) One-year follow-up after a composite restoration and CAF: a good tooth emergenceprofile 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.

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One year after treatment, no local bleeding siteswere present and only three (3%) sites were positivefor the presence of plaque, indicating a marked im-provement in plaque control by patients. No statisti-cally significant difference was demonstrated in localplaque at 1 year among NCCL types.

Clinical Changes at 1 YearIM–GM distance. The results of fitting a general linearstatistical model relating the IM–GM distance to NCCL

types, time, and the interaction between NCCL typesand time showed high R2 statistics, indicating that themodel as fitted was highly significant (F = 22.16;P <0.01)and explained96%of thevariability.Significantrelationship 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 typesand time (F = 43.8; P <0.01). A statistically significantreduction in the IM–GM distance was demonstratedwhen 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 offitting a general linear statistical model relating theIM–GM distance to Miller Classes, time, and the inter-action between Miller Classes and time showed highR2 statistics, indicating that the model as fitted washighly significant (F = 21.1; P <0.01) and explained96% 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 theinteraction between Miller Classes and time (F = 30.9;P <0.01). The baseline and 1-year post-surgical facialaspects of different NCCL types are shown in Figures7 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 statisticalmodel relating KTH to NCCL types, time, and the in-teraction between NCCL types and time showed highR2 statistics, indicating that the model as fitted washighly significant (F = 3.2; P <0.01) and explained78% 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 NCCLtypes and time (F = 12.8; P <0.01). A statisticallysignificant 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 statisticalmodel relating the KTH to Miller Classes, time, andthe interaction between Miller Classes and timeshowed high R2 statistics, indicating that the modelas 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 Classesand time (F = 3.9; P <0.01). The mean keratinizedtissue increase in different NCCL types and MillerClasses are shown in Table 2.

PD. Results of fitting a general linear statisticalmodel relating PD to time, NCCL types, and MillerClasses 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. Thehard tissue defect involved the crown and root causing the disappearanceof the anatomic CEJ. Tooth rotation and the reduction in papillae heightlimited the amount of coverable root; thus, the MRC was located at thelevel of the apical extension of the abrasion defect. B) After the flapelevation and rubber-dam application, a composite filling restored theentire NCCL defect and was finished at the level of the MRC. A goodemergence profile was obtained. C) The composite restoration wellsupported the CAF, which was sutured coronal to the most apicalextension of the composite filling. D) One-year follow-up after thecomposite restoration and CAF: a good tooth emergence profile wasobtained. Compared to the baseline situation, the length of the clinicalcrown was slightly reduced.

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with respect to the baseline mean value (1.1 –0.3 mm).

Patient Satisfaction(VAS)Patient satisfaction with esthetics was very high in alltypes of treatment. Results from the multiple-regres-sion ANOVA relating the patient satisfaction and pa-tient evaluation of root coverage to the color matchand 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 patientsatisfaction; 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 = 36.9and P <0.01 for patient satisfaction; F = 22.8 and P<0.01 for patient root coverage) and not by the rootcoverage (in millimeters) clinically achieved in eachpatient. No statistically significant difference betweenNCCL types and Miller Class gingival recessionswas 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 53.06 – 0.79 3.33 – 0.59 1.92 – 0.54 1.47 – 0.51 0.6 – 0.73

Miller Class 1 II III IV2.69 – 0.67 3.1 – 1.07 1.55 – 0.6 0.4 – 0.69

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satisfaction, color match, and root coverage VASscores. Patient esthetic evaluations in different NCCLtypes are shown in Table 3.

Periodontist Evaluation(VAS)Periodontist evaluations of root coverage, color match,and tooth emergence profile were very high in all typesof treatment. The results from multiple regressionANOVA relating the periodontist evaluation of rootcoverage to the color match and root coverage clini-cally achieved in each patient (in millimeters) showedthat the model was highly statistically significant (F =51.2; P <0.01). However, statistical significance wasonly reached by the color match (F = 99.4; P <0.01)but not by the root coverage clinically achieved ineach patient (F = 2.8; not significant).

No statistically significant difference among NCCLtypes was found in the periodontist evaluation of rootcoverage, color match, and tooth emergence profile.Periodontist esthetic evaluations in different NCCLtypes 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 theperiodontist evaluation of root coverage. However,the results from multiple-range tests showed that onlyMiller Class IV was responsible for the statistical signif-icant difference. No statistically significant differenceamong Miller Classes was found in the periodontistevaluation of the color match and tooth emergenceprofile.

DISCUSSION

The ideal treatment of a crown-radicular NCCLshould consist in a combined restorative/periodontaltreatment in which the restorative therapy is com-pleted before mucogingival surgery. This treatmentfacilitates both procedures: the restorative treat-ment, which can be performed in an well-isolated op-erative field because of the apical dislocation of thesoft 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 NCCLassociated with gingival recession. From a static ap-proach in which the treatment selection was exclu-sively based upon the topographical relationshipbetween the NCCL and CEJ (fixed referring parame-ter), it passed to a dynamic approach that takes intoconsideration the variability in root coverage. Themethod used in the present study to predeterminethe MRC was demonstrated to be reliable in predictingthe 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 gingivalrecession that could be used as the clinical CEJ(cCEJ)5 for the selection of the therapeutic approachof the NCCL associated with gingival recessions:when the cCEJ was located coronal to the NCCL,a periodontal approach (mucogingival surgery) wasindicated; on the contrary, when the cCEJ waslocated apical to the most coronal extension of theNCCL, a combined restorative–periodontal ap-proach is recommended. In the latter case, the cCEJcan be used as a guideline for the apical preparation ofthe composite filling.5

Table 2.

Mean Facial Keratinized Tissue Increase

Keratinized Tissue Increase (mm)

NCCL type 1 2 3 4 50.53 – 0.63 1.55 – 0.98 0.73 – 0.77 0.42 – 0.6 0.53 – 0.83

Miller Class 1 II III IV0.84 – 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 satisfactionVAS ‡80 15 17 26 17 1350£ VAS <80 0 1 1 2 2VAS <50 0 0 0 0 0

Color matchVAS ‡80 15 17 25 17 1350£ VAS <80 0 1 2 2 2VAS <50 0 0 0 0 0

Root coverageVAS ‡80 14 16 25 17 1250£ VAS <80 1 2 2 2 3VAS <50 0 0 0 0 0

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In the present study, the predetermination of theMRC resulted in a decision tree for the treatment ofan NCCL associated with gingival recessions. An ex-cellent esthetic appearance was achieved in the greatmajority of patients affected by NCCLs associatedwith gingival recessions. Although comparative re-sults from non-randomized studies should always beinterpreted with caution, the present study data showsthat patient satisfaction with esthetics as well as pa-tient and periodontist evaluations in terms of root cov-erage were very high with no statistically significantdifference among NCCL types, despite the fact thatdifferent amounts (in millimeters) of root coveragewere achieved. Moreover, no statistically significantrelationships were demonstrated between patientoverall 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 anotherstudy9 on Miller Class I and II gingival recessions,which demonstrated that the periodontist and patientwere well aware of the level of root coverage achievedwith the surgery. In that study,9 a statistically signi-ficant correlation was found between patient satisfac-tion of root coverage (VAS) and the mean percentageof root coverage clinically accomplished in each pa-tient. This discrepancy suggested that when completeroot coverage at the level of the anatomic CEJ cannotbe accomplished, factors other than root coveragemight influence the objective and subjective estheticevaluation of the outcome of a surgical procedure.The present study data suggest that it was the presenceof a different color (yellow dentin) between the white ofthe 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 successfulesthetic evaluation of root coverage. In fact, patientsatisfaction as well as patient and periodontist evalua-tions of root coverage were statistically correlated withcolor-match evaluations (VAS) and not with theamount of root coverage achieved in each patient.

Also, the data of the present study show that onlyMiller Class IV was responsible for the statistical signif-icant difference among Miller Classes in the periodon-tist evaluation of root coverage supports the proposedtreatment approach of an NCCL associated with gin-gival recessions. The restorative–periodontal ap-proach did not allow the evaluating periodontist torealize that incomplete root coverage was achievedin the Miller Class III gingival recessions despite thepresence of clinical and anatomic conditions limitingthe amount of root coverage.

The present study also demonstrates that an excel-lent tooth emergence profile was obtained in the greatmajority of teeth affected by cervical abrasions withno statistically significant difference between NCCLtypes and Miller Class gingival recessions. The objec-tive evaluation of the tooth emergence profile, evenif performed by an experienced periodontist, cannotbe considered an absolute value of the present studysince conclusive and universally accepted parame-ters to define a correct emergence profile are not clar-ified. However, the absence of BOP at the facial aspectof all treated sites together with the marked reductionof local plaque scores suggested that the tooth emer-gence profiles accomplished in the present clinicaltrial were easy to clean by patients. In addition, the in-crease in KTH might also have contributed to improvethe facial plaque control by patients.

CONCLUSIONS

Within the limitsof the presentpilot study, it canbesug-gested that: 1) the predetermination of the MRC can beused for the selection of the treatment approach of anNCCL associated with gingival recessions; 2) the pres-ent treatment approach provided a good esthetic ap-pearance and correct emergence profile to the greatmajority of teeth affected by NCCLs; and 3) the patientoverall satisfaction as well as the patient and periodon-tist evaluations of root coverage were statistically cor-related with color-match evaluations (VAS) and notwith the amount of root coverage (in millimeters)achieved in each patient. Additional randomized clini-cal studies are advocated to test the efficacy of thepresent treatment approach for NCCLs associated withgingival recessions.

ACKNOWLEDGMENTS

This case study was self-supported by the authors.The authors report no conflicts of interest related tothis case series.

Table 4.

Periodontist Esthetic Evaluation

NCCL Type (n patients)

Parameters 1 (15) 2 (18) 3 (27) 4 (19) 5 (15)

Root coverageVAS ‡80 14 16 22 14 950£ VAS <80 1 2 5 5 6VAS <50 0 0 0 0 0

Color matchVAS ‡80 14 16 23 16 1250£ VAS<80 1 2 4 3 3VAS <50 0 0 0 0 0

Tooth emergence profileVAS ‡80 13 13 21 14 1050£ VAS <80 2 5 6 5 5VAS <50 0 0 0 0 0

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corrosion and abfraction revisited: A new perspectiveon tooth surface lesions. J Am Dent Assoc 2004;135:1109-1118; quiz 1163-1165.

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5. Zucchelli G, Testori T, De Sanctis M. Clinical andanatomical factors limiting treatment outcomes ofgingival recession: A new method to predeterminethe line of root coverage. J Periodontol 2006;77:714-721.

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7. Zucchelli G, Mele M, Stefanini M, et al. Predetermina-tion of root coverage. J Periodontol 2010;81:1019-1026.

8. Cortellini P, Tonetti M, Baldi C, et al. Does placementof a connective tissue graft improve the outcomes ofcoronally advanced flap for coverage of single gingivalrecessions in upper anterior teeth? A multi-centre,randomized, double-blind, clinical trial. J Clin Peri-odontol 2009;36:68-79.

9. Zucchelli G, Mele M, Mazzotti C, Marzadori M,Montebugnoli L, De Sanctis M. Coronally advancedflap with and without vertical releasing incisions for thetreatment of multiple gingival recessions: A compar-ative controlled randomized clinical trial. J Periodontol2009;80:1083-1094.

10. O’Leary TJ, Drake RB, Naylor JE. The plaque controlrecord. J Periodontol 1972;43:38.

11. Aichelmann-Reidy ME, Yukna RA, Evans GH, NasrHF, Mayer ET. Clinical evaluation of acellular allograftdermis for the treatment of human gingival recession.J Periodontol 2001;72:998-1005.

12. Wang HL, Bunyaratavej P, Labadie M, Shyr Y, MacNeilRL. Comparison of 2 clinical techniques for treatment ofgingival recession. J Periodontol 2001;72:1301-1311.

13. de Sanctis M, Zucchelli G. Coronally advanced flap: Amodified surgical approach for isolated recession-typedefects: Three-year results. J Clin Periodontol 2007;34:262-268.

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Correspondence: Prof. Giovanni Zucchelli, Department ofStomatology, University of Bologna, Via S. Vitale 59, 40125Bologna, Italy. Fax: 39-051-225208; e-mail: giovanni.zucchell@unibo.it

Submitted February 7, 2011; accepted for publicationMarch 14, 2011.

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