Professional Documents
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Volume 82 Number 12
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Volume 82 Number 12
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 flap and root concavity, apical to the MRC, was
occupied by blood coagulum (red area). E) NCCL type 4: the MRC (arrow) was located apical to the deepest portion of the abrasion defect due to a
mild loss of papilla height (black area). The treatment consisted of a composite restoration (light-blue area) 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 sharpness and depth of the coronal step of the NCCL and
was extended more and more occlusally with the increasing depth of the hard tissue defect. The grinded
area was restored with a composite filling that was
extended up to the MRC. The coronal odontoplasty
made at the level of the enamel created a long bevel
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.
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Volume 82 Number 12
RESULTS
A total of 94 gingival recessions
were treated. There were 26 Miller
Class I recessions, 20 Miller Class
II recessions, 38 Miller Class III
recessions (including rotated or
malpositioned and extruded
teeth with or without an occlusal
abrasion and teeth with some
loss of papillae height), and 10
Miller Class IV recessions.
There were 15 (16%) type 1
NCCLs, of which 10 were associated with Miller Class I gingival
recessions, and five NCCLs were
associated with Miller Class II gingival recessions; 18 (19%) type 2
NCCLs, of which eight were asFigure 5.
NCCL type 4. A) Upper canine with a shallow NCCL and deep gingival recession. The NCCL area involved
sociated with Miller Class I ginthe crown and root causing the disappearance of the anatomic CEJ. The MRC was located apical to the
gival recessions, and 10 NCCLs
deepest portion of the abrasion defect. B) A composite filling restored the deepest portion of the NCCL
were associated with Miller Class
defect and was finished at the level of the MRC. A good emergence profile was obtained. C) The portion
II gingival recessions; 27 (29%)
of the hard tissue defect apical to the MRC was planned after a flap elevation. D) The profile of the
type 3 NCCLs, of which four were
restoration well supported the CAF, which was sutured coronal to the most apical extension of the
composite filling. E) One-year follow-up after a composite restoration and CAF: a good tooth emergence
associated with Miller Class I
profile was obtained. Note that the coronal portion of the abrasion space was filled with composite,
gingival recessions, three were
whereas the apical part seemed to be filled by the increased thickness of the facial gingival tissue.
associated with Miller Class II gingival recessions, and 20 NCCLs
were associated with Miller
expressed as means SDs. General linear models
Class III gingival recessions; 19 (20.2%) type 4
were fitted, and multiple regression one-way analysis
NCCLs, of which four were associated with the Miller
of variance (ANOVA) for repeated measures with a
Class I gingival recessions, two were associated with
split-plot design was used to evaluate the existence
Miller Class II gingival recessions, and 13 were assoof any significant difference regarding local plaque,
ciated with Miller Class III gingival recessions; and 15
local bleeding, IMGM distance, KTH, and PD among
(16%) type 5 NCCLs, of which five were associated
NCCL types or Miller Classes, time (1 year versus
with Miller Class III gingival recessions, and 10 were
baseline), and the interaction between NCCL types
associated with Miller Class IV gingival recessions.
or Miller Classes and time. In case of significance,
the Bonferroni t test was applied as a multiple-comOral Hygiene
parison test.
After the initial oral hygiene phase and at post-treatment
After controlling for standardized skewness and
examinations, all patients showed low frequencies of
standardized kurtosis values for satisfaction, the
plaque-harboring tooth surfaces (full-mouth plaque
color match and root coverage by the patient and
score <20%) and bleeding gingival units (full-mouth
color match, emergence profile, and root coverage
bleeding score <15%), indicating a good standard of
by the periodontist were all within the range expected
supragingival plaque control during the study period.
for data from a normal distribution; one-way ANOVA
The results of fitting a general linear statistical
was used to evaluate the presence of any significant
model relating local plaque to NCCL types, time,
difference among NCCL types and Miller Classes.
and the interaction between NCCL types and time
The Fisher least-significant difference procedure was
showed high R2 statistics indicating that the model
used to discriminate among means.
as fitted was significant (F = 1.6; P <0.02) and exMultiple linear regression models were fitted to
plained 66% of the variability. A significant relationdescribe the relationship between patient overall
ship was found regarding time-related differences
satisfaction as well as patient and periodontist eval(F = 26.8l P <0.01), whereas no significant difference
uations of root coverage and patient and periodonwas found concerning NCCL types or the interaction
tist evaluations of color match and root coverage
between NCCL types and time. At baseline, local (fa(in millimeters) that were clinically achieved with
cial) plaque was demonstrated in 26 (28%) treated
the surgery.
sites. Local bleeding was recorded in 22 (23%) sites.
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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.
Volume 82 Number 12
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.
1
3.06 0.79
2
3.33 0.59
3
1.92 0.54
4
1.47 0.51
Miller Class
1
2.69 0.67
II
3.1 1.07
III
1.55 0.6
IV
0.4 0.69
5
0.6 0.73
Volume 82 Number 12
Table 2.
1
0.53 0.63
2
1.55 0.98
3
0.73 0.77
Miller Class
1
0.84 0.92
II
1.3 0.92
III
0.55 0.82
Table 3.
1 (15)
2 (18)
3 (27)
4 (19)
5 (15)
Overall satisfaction
VAS 80
15
50 VAS <80
0
VAS <50
0
17
1
0
26
1
0
17
2
0
13
2
0
Color match
VAS 80
50 VAS <80
VAS <50
15
0
0
17
1
0
25
2
0
17
2
0
13
2
0
Root coverage
VAS 80
50 VAS <80
VAS <50
14
1
0
16
2
0
25
2
0
17
2
0
12
3
0
4
0.42 0.6
5
0.53 0.83
IV
0.3 0.67
Table 4.
1 (15)
2 (18)
3 (27)
4 (19)
5 (15)
Root coverage
VAS 80
50 VAS <80
VAS <50
14
1
0
16
2
0
22
5
0
14
5
0
9
6
0
Color match
VAS 80
50 VAS<80
VAS <50
14
1
0
16
2
0
23
4
0
16
3
0
12
3
0
13
5
0
21
6
0
14
5
0
10
5
0
REFERENCES
1. Grippo JO, Simring M, Schreiner S. Attrition, abrasion,
corrosion and abfraction revisited: A new perspective
on tooth surface lesions. J Am Dent Assoc 2004;135:
1109-1118; quiz 1163-1165.
2. Bartlett DW, Shah P. A critical review of non-carious
cervical (wear) lesions and the role of abfraction,
erosion, and abrasion. J Dent Res 2006;85:306312.
3. Levitch LC, Bader JD, Shugars DA, Heymann HO.
Non-carious cervical lesions. J Dent 1994;22:195-207.
4. Hand JS, Hunt RJ, Reinhardt JW. The prevalence and
treatment implications of cervical abrasion in the
elderly. Gerodontics 1986;2:167-170.
5. Zucchelli G, Testori T, De Sanctis M. Clinical and
anatomical factors limiting treatment outcomes of
gingival recession: A new method to predetermine
the line of root coverage. J Periodontol 2006;77:714721.
6. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5(2):
8-13.
7. Zucchelli G, Mele M, Stefanini M, et al. Predetermination of root coverage. J Periodontol 2010;81:10191026.
8. Cortellini P, Tonetti M, Baldi C, et al. Does placement
of a connective tissue graft improve the outcomes of
coronally advanced flap for coverage of single gingival
recessions in upper anterior teeth? A multi-centre,
randomized, double-blind, clinical trial. J Clin Periodontol 2009;36:68-79.
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