J Periodontol • December 2011

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-

A
thetic evaluations. non-carious cervical lesion (NCCL)
Methods: Five treatments were performed in 94 patients is described as the wear of the
with NCCLs associated with a single gingival recession: 1) tooth substance at the level of the
coronally advanced flap (CAF); 2) bilaminar procedure; 3) gingival one-third of the tooth due to
coronal odontoplasty plus restoration plus root odontoplasty reasons other than dental caries.1,2 Al-
plus CAF; 4) restoration plus CAF; and 5) restorative therapy. though an abrasion, due to mechanical
Clinical and esthetic evaluations made by the patient and an forces,3 plays an important role in the
independent periodontist were done 1 year after treatments. development of NCCLs, it is not the sole
Results: The satisfaction of the patient and periodontist cause, and it is generally accepted that
with esthetics was very high in all NCCL treatments and Miller the etiology of NCCLs is multifactorial,
Class gingival recessions. The patient satisfaction and evalu- involving other factors such as corro-
ation of root coverage and the periodontist evaluation of root sion, and possibly abfraction, as well.1,2
coverage were statistically correlated with color-match evalu- Main indications4 for the treatment of an
ations and not with the amount of root coverage clinically NCCL are: 1) esthetics, especially when
achieved in each patient. the lesion is pigmented and/or associated
Conclusion: The proposed approaches provided good with gingival recession; 2) dentin hyper-
esthetic appearance and correct emergence profile for the sensitivity, which may be the cause of
great majority of NCCLs associated with gingival recessions. discomfort/pain or faulty plaque control
J Periodontol 2011;82:1713-1724. for the patient; 3) caries/demineralization
with or without dentin hypersensitivity;
KEY WORDS and 4) bacterial plaque accumulation
Cemento-enamel junction; gingival recession; surgery. due to the shape and/or depth of abrasion
that make oral health care difficult/in-
* Department of Periodontology, School of Dentistry, Bologna University, Bologna, Italy. effective.
† Private practice, Rome, Italy. From a topographic standpoint, an
‡ Department of Stomatology, Bologna University.
§ Department of Periodontology, Siena University, Siena, Italy. 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 commonly associated
with gingival recession. An NCCL involving

doi: 10.1902/jop.2011.110080

1713
Treatment of Non-Carious Cervical Lesions
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
complex and, frequently, the NCCL involves both 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.
1714
Volume 82 • Number 12
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 in which it was not possible to predetermine
the MRC (the absence of a contact point in the tooth
with gingival recession and in the homologous contra-
lateral one) or that had prosthetic crowns or composite
restorations extending on the facial root surface were
excluded from the study. Patients who smoked >10
cigarettes a day were also excluded. Recession defects
associated with evidence of pulpal pathology were not
included, and molar teeth were excluded.
Study Design
This was a pilot, case-series study selecting different
treatment approaches for NCCL associated with gin-
gival recessions according to the 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
J Periodontol • December 2011
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
Zucchelli, Gori, Mele, et al.
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 (capable of 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-
ment performed. 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.
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Treatment of Non-Carious Cervical Lesions Volume 82 • Number 12

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 the MRC 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 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.

1716
J Periodontol • December 2011 Zucchelli, Gori, Mele, et al.

NCCL. The coronal odontoplasty reduced the sharp- that improved the adhesion of the restorative material.
ness and depth of the coronal step of the NCCL and The exposed root surface apical to the MRC was used
was extended more and more occlusally with the in- for isolating the operative field by a rubber dam. If and
creasing depth of the hard tissue defect. The grinded when the NCCL reached or extended beyond the soft
area was restored with a composite filling that was tissue margin, it was necessary to the elevate the flap
extended up to the MRC. The coronal odontoplasty before performing the composite restoration to ex-
made at the level of the enamel created a long bevel 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-
Figure 2. ite filling. The conservative fill-
NCCL type 1. A) Canine with gingival recession and a shallow radicular NCCL defect. The hard tissue defect ing facilitated the surgery by
was completely coverable with soft tissues. B) Root surface and NCCL area were mechanically treated providing a smooth, convex,
after a flap elevation. C) The flap was coronally advanced and sutured coronal to the CEJ. D) One-year and stable substrate for the cor-
follow-up after the CAF surgical technique: complete root coverage and a good emergence profile were
onal stabilization of the surgical
obtained. The NCCL defect appeared to be filled by an increased facial soft-tissue thickness.
flap.

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.

1717
Treatment of Non-Carious Cervical Lesions Volume 82 • Number 12

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 flap was positioned 1 mm coronal to the api-
cal extension of the composite filling.
Post-Surgical Instructions and Infection
Control
Postoperative pain and edema were controlled
Figure 4. with ibuprofen. Patients received a 600 mg tablet
NCCL type 3. A) Upper canine with gingival recession and a deep NCCL defect.
at the beginning of the surgical procedure and
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 were instructed to take another tablet 6 hours
defect. B) The depth of the NCCL was reduced by means of a coronal odontoplasty, later. Subsequent doses were taken only if neces-
and the crown emergence profile was restored with a composite filling. C) Flap sary to control pain. Patients were instructed not
elevation. D) The profile of the composite was used as a guide for the correct to brush in the treated area but to rinse with a
planning of the root surface (root odontoplasty). E) The flap was coronally advanced
0.12% chlorhexidine solution three times a day
and secured coronal to the most apical extension of the composite restoration. The
conservative therapy facilitated the surgery by providing a smooth, convex, and for 1 minute. Fourteen days after the surgical
stable substrate for the coronal stabilization of the surgical flap. F) One-year treatment, sutures were removed. Plaque control
follow-up: a tooth emergence profile that was easy for the patient to clean and in the surgically treated area was maintained by
protecting the soft tissue margin was obtained. chlorhexidine rinsing for an additional 2 weeks.
After this period, patients were again instructed
in mechanical tooth cleaning of the treated tooth using
Type 4. NCCL type 4 was a radicular NCCL asso-
an ultrasoft toothbrush and a roll technique for 1 month.
ciated with Miller Class III gingival recessions or
During this period, chlorhexidine rinse was used twice
a crown-root NCCL associated with Miller Class I
daily. Then, the patient started to use a soft-toothbrush
or II gingival recession (Fig. 5) in which the deepest
and to rinse with chlorhexidine once a day. All patients
portion of the NCCL defect was localized at the
were recalled for prophylaxis 2 and 4 weeks after suture
level of the anatomic crown and only the apical por-
removal and, subsequently, once every 2 months until
tion of the NCCL involved the root. In both of
the final examination (12 months).
these circumstances, the deepest portion of the
NCCL was not coverable with soft tissue; thus, it
Data Analyses
was treated with the composite filling that was
A statistical application software¶ was used for
extended up to the MRC. The exposed root surface
the statistical analysis. Descriptive statistics were
apical to the MRC was used for isolating the opera-
tive field by a rubber dam. If this was not feasible, ¶ SAS version 6.09, SAS Institute, Cary, NC.

1718
J Periodontol • December 2011 Zucchelli, Gori, Mele, et al.

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 associ-
ated with Miller Class I gingival
recessions, and five NCCLs were
associated with Miller Class II gin-
gival recessions; 18 (19%) type 2
Figure 5. NCCLs, of which eight were as-
NCCL type 4. A) Upper canine with a shallow NCCL and deep gingival recession. The NCCL area involved sociated with Miller Class I gin-
the 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
of the hard tissue defect apical to the MRC was planned after a flap elevation. D) The profile of the II gingival recessions; 27 (29%)
restoration well supported the CAF, which was sutured coronal to the most apical extension of the type 3 NCCLs, of which four were
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 gin-
gival 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 asso-
of any significant difference regarding local plaque, ciated with Miller Class III gingival recessions; and 15
local bleeding, IM–GM 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-com- Oral 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 ex-
Multiple linear regression models were fitted to plained 66% of the variability. A significant relation-
describe 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 periodon- was 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.

1719
Treatment of Non-Carious Cervical Lesions
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.
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
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Volume 82 • Number 12
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 explained 96% of the variability. 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 were
found 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 KTH was demonstrated com-
paring baseline (1.58 – 0.62 mm) with 1-year (2.35 –
0.8 mm) KTH mean values. The overall increase in ker-
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
J Periodontol • December 2011 Zucchelli, Gori, Mele, et al.

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

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

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Treatment of Non-Carious Cervical Lesions Volume 82 • Number 12

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.
ence (F = 4.3; P <0.01) among Miller Classes in the
Patient Esthetic Evaluation periodontist evaluation of root coverage. However,
the results from multiple-range tests showed that only
NCCL Type (n patients) Miller Class IV was responsible for the statistical signif-
icant difference. No statistically significant difference
Parameters 1 (15) 2 (18) 3 (27) 4 (19) 5 (15)
among Miller Classes was found in the periodontist
Overall satisfaction evaluation of the color match and tooth emergence
VAS ‡80 15 17 26 17 13 profile.
50£ VAS <80 0 1 1 2 2
VAS <50 0 0 0 0 0 DISCUSSION
Color match The ideal treatment of a crown-radicular NCCL
VAS ‡80 15 17 25 17 13 should consist in a combined restorative/periodontal
50£ VAS <80 0 1 2 2 2 treatment in which the restorative therapy is com-
VAS <50 0 0 0 0 0 pleted before mucogingival surgery. This treatment
Root coverage facilitates both procedures: the restorative treat-
VAS ‡80 14 16 25 17 12 ment, which can be performed in an well-isolated op-
50£ VAS <80 1 2 2 2 3 erative field because of the apical dislocation of the
VAS <50 0 0 0 0 0 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
satisfaction, color match, and root coverage VAS associated with gingival recession. From a static ap-
scores. Patient esthetic evaluations in different NCCL proach in which the treatment selection was exclu-
types are shown in Table 3. sively based upon the topographical relationship
between the NCCL and CEJ (fixed referring parame-
Periodontist Evaluation(VAS) ter), it passed to a dynamic approach that takes into
Periodontist evaluations of root coverage, color match, consideration the variability in root coverage. The
and tooth emergence profile were very high in all types method used in the present study to predetermine
of treatment. The results from multiple regression the MRC was demonstrated to be reliable in predicting
ANOVA relating the periodontist evaluation of root the position of the soft tissue margin after root cover-
coverage to the color match and root coverage clini- age surgery.7 It allowed for the identification of a scal-
cally achieved in each patient (in millimeters) showed loped line (MRC) in all teeth affected by gingival
that the model was highly statistically significant (F = recession that could be used as the clinical CEJ
51.2; P <0.01). However, statistical significance was (cCEJ)5 for the selection of the therapeutic approach
only reached by the color match (F = 99.4; P <0.01) of the NCCL associated with gingival recessions:
but not by the root coverage clinically achieved in when the cCEJ was located coronal to the NCCL,
each patient (F = 2.8; not significant). a periodontal approach (mucogingival surgery) was
No statistically significant difference among NCCL indicated; on the contrary, when the cCEJ was
types was found in the periodontist evaluation of root located apical to the most coronal extension of the
coverage, color match, and tooth emergence profile. NCCL, a combined restorative–periodontal ap-
Periodontist esthetic evaluations in different NCCL proach is recommended. In the latter case, the cCEJ
types are shown in Table 4. Results from one-way AN- can be used as a guideline for the apical preparation of
OVA demonstrated a statistically significant differ- the composite filling.5

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J Periodontol • December 2011 Zucchelli, Gori, Mele, et al.

Table 4. sue margin, that was critical in terms of a successful

esthetic evaluation of root coverage. In fact, patient
Periodontist Esthetic Evaluation
satisfaction as well as patient and periodontist evalua-
tions of root coverage were statistically correlated with
NCCL Type (n patients)
color-match evaluations (VAS) and not with the
Parameters 1 (15) 2 (18) 3 (27) 4 (19) 5 (15) amount of root coverage achieved in each patient.
Also, the data of the present study show that only
Root coverage
Miller Class IV was responsible for the statistical signif-
VAS ‡80 14 16 22 14 9
50£ VAS <80 1 2 5 5 6 icant difference among Miller Classes in the periodon-
VAS <50 0 0 0 0 0 tist evaluation of root coverage supports the proposed
treatment approach of an NCCL associated with gin-
Color match gival recessions. The restorative–periodontal ap-
VAS ‡80 14 16 23 16 12 proach did not allow the evaluating periodontist to
50£ VAS<80 1 2 4 3 3
realize that incomplete root coverage was achieved
VAS <50 0 0 0 0 0
in the Miller Class III gingival recessions despite the
Tooth emergence profile presence of clinical and anatomic conditions limiting
VAS ‡80 13 13 21 14 10 the amount of root coverage.
50£ VAS <80 2 5 6 5 5 The present study also demonstrates that an excel-
VAS <50 0 0 0 0 0 lent tooth emergence profile was obtained in the great
majority of teeth affected by cervical abrasions with
no statistically significant difference between NCCL
In the present study, the predetermination of the types and Miller Class gingival recessions. The objec-
MRC resulted in a decision tree for the treatment of tive evaluation of the tooth emergence profile, even
an NCCL associated with gingival recessions. An ex- if performed by an experienced periodontist, cannot
cellent esthetic appearance was achieved in the great be considered an absolute value of the present study
majority of patients affected by NCCLs associated since conclusive and universally accepted parame-
with gingival recessions. Although comparative re- ters to define a correct emergence profile are not clar-
sults from non-randomized studies should always be ified. However, the absence of BOP at the facial aspect
interpreted with caution, the present study data shows of all treated sites together with the marked reduction
that patient satisfaction with esthetics as well as pa- of local plaque scores suggested that the tooth emer-
tient and periodontist evaluations in terms of root cov- gence profiles accomplished in the present clinical
erage were very high with no statistically significant trial were easy to clean by patients. In addition, the in-
difference among NCCL types, despite the fact that crease in KTH might also have contributed to improve
different amounts (in millimeters) of root coverage the facial plaque control by patients.
were achieved. Moreover, no statistically significant
relationships were demonstrated between patient CONCLUSIONS
overall satisfaction and patient/periodontist evalua- Within the limits of the present pilot study, it can be sug-
tions of root coverage and the amount (in millimeters) gested that: 1) the predetermination of the MRC can be
of root coverage clinically achieved in each patient. used for the selection of the treatment approach of an
These results are in contrast with the results of another NCCL associated with gingival recessions; 2) the pres-
study9 on Miller Class I and II gingival recessions, ent treatment approach provided a good esthetic ap-
which demonstrated that the periodontist and patient pearance and correct emergence profile to the great
were well aware of the level of root coverage achieved majority of teeth affected by NCCLs; and 3) the patient
with the surgery. In that study,9 a statistically signi- overall satisfaction as well as the patient and periodon-
ficant correlation was found between patient satisfac- tist evaluations of root coverage were statistically cor-
tion of root coverage (VAS) and the mean percentage related with color-match evaluations (VAS) and not
of root coverage clinically accomplished in each pa- with the amount of root coverage (in millimeters)
tient. This discrepancy suggested that when complete achieved in each patient. Additional randomized clini-
root coverage at the level of the anatomic CEJ cannot cal studies are advocated to test the efficacy of the
be accomplished, factors other than root coverage present treatment approach for NCCLs associated with
might influence the objective and subjective esthetic gingival recessions.
evaluation of the outcome of a surgical procedure.
The present study data suggest that it was the presence ACKNOWLEDGMENTS
of a different color (yellow dentin) between the white of This case study was self-supported by the authors.
the enamel/composite and the pink/red of the soft tis- The authors report no conflicts of interest related to
sue, more than the apical-coronal level of the soft tis- this case series.

1723
Treatment of Non-Carious Cervical Lesions
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;85:306-
312.
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;77:714-
721.
6. Miller PD Jr. A classification of marginal tissue re-
cession. Int J Periodontics Restorative Dent 1985;5(2):
8-13.
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 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 Peri-
odontol 2009;36:68-79.
1724
Volume 82 • Number 12
9. Zucchelli G, Mele M, Mazzotti C, Marzadori M,
Montebugnoli L, De Sanctis M. Coronally advanced
flap with and without vertical releasing incisions for the
treatment of multiple gingival recessions: A compar-
ative controlled randomized clinical trial. J Periodontol
2009;80:1083-1094.
10. O’Leary TJ, Drake RB, Naylor JE. The plaque control
record. J Periodontol 1972;43:38.
11. Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr
HF, Mayer ET. Clinical evaluation of acellular allograft
dermis for the treatment of human gingival recession.
J Periodontol 2001;72:998-1005.
12. Wang HL, Bunyaratavej P, Labadie M, Shyr Y, MacNeil
RL. Comparison of 2 clinical techniques for treatment of
gingival recession. J Periodontol 2001;72:1301-1311.
13. de Sanctis M, Zucchelli G. Coronally advanced flap: A
modified surgical approach for isolated recession-type
defects: Three-year results. J Clin Periodontol 2007;
34:262-268.
14. Zucchelli G, Amore C, Sforzal NM, Montebugnoli L, De
Sanctis M. Bilaminar techniques for the treatment of
recession-type defects. A comparative clinical study.
J Clin Periodontol 2003;30:862-870.
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.