An interdisciplinary approach for the management of noncarious lesions.

Miller's class III gingival recession is a common entity observed in individuals, posing a difficult situation for the clinicians to treat. Large fenestration defects with cervical abrasion compromise the esthetics resulting in poor prognosis. Obtaining predictable and esthetic root coverage has become an integral part of periodontal therapy. The present case report describes a situation where class III gingival recession with cervical abrasion was seen in the lower central incisors. The patient was successfully treated with a combination of restorations (Filtek Z350(®) composite resin) to fill the defect, followed by fenestration procedure to increase the vestibular depth and subsequently with grafting procedure (soft tissue autograft with bovine-derived xenograft collagen [Bio-oss]). Though the results were not tangible esthetically, it was functionally successful as evidenced during the follow-up period.

INTRODUCTION

An interdisciplinary approach to treating cervical lesions will create the most biologically appropriate, stable and esthetic outcome. Soft tissue grafting is an integral part of the treatment of cervical lesions due to lack of adequate attached gingiva and root exposure associated with these lesions. There are three types of cervical lesions (a) noncarious cervical lesions (b) restored cervical lesions and (c) carious cervical lesions. Etiology of non carious cervical lesions are multifactorial in nature [Table 1].[1] These cervical lesions are classified according to their depth and extent of enamel involvement [Table 2].[2]

Table 1

Etiology of noncarious lesions is multifactorial in nature[1]

Table 2

Classification of cervical lesions[2]

Complete root coverage is a predictable outcome for Miller's I and II recession defects whereas partial root coverage can be achieved in Miller's III defects [Table 3]. Restorations are required for cervical lesions with excessive depth and significant involvement of the enamel. Some of the defects require both soft tissue grafting and the placement of a restoration.

Table 3

Interdisciplinary treatment of cervical lesions[3]

Treatment planning can be done by assessment of five variables (a) gingival dimensions (b) depth of cervical lesion (c) depth of recession (d) location of the lesion and (e) classification of recession [Table 4].[3]

Table 4

Treatment guidelines[3]

Gingival recession is described as “the exposure of the root surface by an apical shift in the position of the gingiva.”[4] Problems commonly associated with the presence of gingival recession are compromised esthetics, root hypersensitivity, higher incidence of root caries, and compromised plaque control.[5] Various mucogingival procedures for the surgical treatment of gingival recession have been investigated in several clinical studies. A number of new surgical procedures have been developed, increasing the range of available treatment options. The lateral sliding flap for coverage of exposed roots is generally attributed to Grupe and Warren in 1956.[6] This procedure is associated with a risk of recession in the donor area if the alveolar bone is thin at the donor site. To solve this problem, Espinel and Caffesse (1981) covered the donor site with free gingival graft, to cover denuded roots, showing varying rates of success depending on factors related to the surgical techniques and anatomical features of the lesions. Establishing the correct tooth form for the patient is based on esthetics, phonetics, and function.

The critical component to the esthetic appearance of the tooth depends on their length and width ratio. To optimize tooth proportion, we need to know (a) incisal edge position (b) tooth length and (c) gingival level. When performing either root coverage grafting or esthetic crown lengthening, determination of optimal tooth form is necessary before determining where to keep the gingival level, hence maintaining the harmony between adjacent soft tissue levels and the contralateral tooth.

Pathological noncarious loss of tooth tissues results from:

Chemical action not involving bacteria (erosion)

Wear due to tooth-to-tooth contact during mastication (attrition)

Mechanical or frictional forces (abrasion)

Strong eccentric occlusal forces (abfraction).

CASE REPORT

A 49-year-old apparently healthy man with a history of smoking came to the Outpatient Department of Periodontics of A. J. Institute of Dental Sciences with a chief complaint of receded gums in relation to the lower anteriors. The patient is a carpenter by profession and did not have any known medical ailment. On intraoral examination, he had generalized cervical abrasion. Erosion was seen with respect to 11, 13, 21, 22, and 23. P. D. Miller's (Jr) class II recession was present in relation to 31, 32, 42, and 43 and class III recession in relation to 41. Midline diastema was present in relation to 11, 21 and 31, 41. The patient also had decreased width of attached gingiva in relation to the lower anteriors and clinical attachment loss of 6 mm with respect to 41 and 4 mm with respect to 31, 32, 42, and 43 [Figure 1]. Radiographs were taken on the first visit, which showed interdental and vertical bone loss with respect to 31 and 41 [Figure 2]. A detailed case history was recorded, and treatment was planned meticulously. Verbal and written consent was obtained from the patient.

Figure 1

First visit

Figure 2

Radiograph taken on the 1st visit

The treatment protocol was as follows:

Supragingival and subgingival scaling and root planing

Restorative treatment for cervical erosions and abrasions

Frenectomy and fenestration procedure to deepen the vestibule

Evaluation of the increase in the width of attached gingiva

Regenerative therapy to correct the ridge defect and the gingival recession in relation to the lower anteriors

Postsurgical maintenance therapy.

On the first visit, thorough supragingival and subgingival scaling and root planing were performed, and oral hygiene instructions were given. The patient was counseled to quit smoking. He was recalled for restorative procedures. On the second visit, cervical abrasions and erosions were restored using composite restoration (Filtek Z350®) [Figure 3]. On the third visit, frenectomy of the mandibular labial frenum and fenestration procedure were done to achieve an adequate width of attached gingiva [Figure 4]. The depth of the vestibule was increased by 3 mm after 3 weeks [Figure 5].

Figure 3

On the 2nd visit - Cervical abrasions and erosions were restored using composite restoration (Filtek Z350®)

Figure 4

On the 3rd visit, Frenectomy of the labial frenum and fenestration procedure were done

Figure 5

Depth of the vestibule was increased by 3 mm after 3 weeks

On the fifth visit, free gingival soft tissue autograft procedure was performed for root coverage. Evaluation of the length and width of the graft needed was done in the recipient site. After administration of local anesthesia, root planing and flattening of the root surface were done. The recipient bed was prepared with 2 horizontal incisions on the interdental papillae adjacent to the recession. These horizontal incisions were connected with 2 vertical incisions on either side of the recession. Preparation of the recipient site was done and bone graft (Bio-oss) was placed interdentally between 31 and 41 to build up the ridge defect. A split thickness flap was elevated from the palate, 1½ times more than the size that was required to compensate for the shrinkage. The palatal graft was raised from the donor site using tin foil as a template and was secured with 4–0 silk interrupted sutures, and a periodontal dressing was placed. The flap was placed in the recipient site and sutured [Figure 6].

Figure 6

(a) Measuring horizontal recession in relation to 31, 41; (b) preparation of recipient bed and graft placement; (c) donor site; (d) excision of soft tissue from donor site (palate); (e) soft tissue autograft; (f) placement of graft on recipient site; (g) suture placed

The patient was recalled after 10 days for follow-up, and the healing was found to be satisfactory. Subsequently, the patient was followed up for 2 months. Attachment gain of 2 mm was observed after 2 months [Figure 7]. Postoperative radiographs taken after 2 months showed 1 mm bone fill [Figure 8]. Preoperative and postoperative photographs have been compared [Figure 9]. Review after 6 months was also done, showing attachment gain of another 1 mm [Figure 10].

Figure 7

Attachment gain of 2 mm after 2 months

Figure 8

Postoperative radiograph taken after 2 months

Figure 9

Preoperative and Postoperative

Figure 10

Postoperative photograph after 6 months

The result of this case indicated that while complete root coverage was not possible, nearly 50% of the denuded root surfaces could be covered with free gingival graft in class III recession, contributing to the overall improvement in the periodontal health.

DISCUSSION

In this case, free gingival autograft was used for the coverage of gingival recession on a previously restored tooth. Bridging or creeping attachment is seen with free gingival graft. In the case of bridging, some of the grafted tissue will remain vital over the avascular zone, i.e. the root. Creeping attachment described by Otero-Cagide and Otero-Cagide[7] is the result of coronal migration of the grafted gingiva and will take place during the years following surgery. The formation of long junctional epithelium is the predominant type of healing, with the absence of connective tissue attachment and new bone formation onto the restorative materials. Santamaria et al.[8] did a study to evaluate the treatment of gingival recession associated with noncarious cervical lesions by placing a soft tissue graft on a previously restored tooth surface. The results of the study were good.

In our case, the creeping attachment had taken place 2 months after the gingival grafting procedure. Matter and Cimasoni[9] described 5 factors that seemed to have a definite influence on creeping attachment, i.e. the width of the recession, the position of the graft, interproximal bone resorption, position of the tooth and the patient's dental hygiene.[9] The degree of creeping attachment, in this case, is unique, given the width and length of the recession defect, the tooth type, the presence of a restoration and the patient's age. Clinically, evident recession was still present 2 months after the procedure. According to Matter and Cimasoni, the creeping attachment typically occurs within 1–12 months after the graft procedure. A graft can predictably cover a root to within 3 mm of the adjacent papillae tips. If there is a difference between the mesial and distal papilla heights, the shorter of the two papillae will determine the level of root coverage. Thus ideally, a restoration should not extend more than 3 mm apically from the papilla tip, leaving the rest of the root exposed for root coverage grafting.[10] However, in this case, further follow-up showed considerable increase in the creeping attachment. Restoration of cervical lesions such as abrasion and erosion should be done prior to placing the gingival level back to its ideal position. Class V restorations may be required if there is excessive depth to the lesion or significant loss of anatomic crown form. The best materials for restoration of the noncervical carious lesion (NCCLs) are composite resins. Within this group of materials, some authors recommend that NCCLs suspected of being caused primarily by abfraction should be restored with a microfilled resin composite or a flowable resin that has a low modulus of elasticity, as it will flex with the tooth and not compromise retention.[1112] In the case of deep NCCLs, a laminate technique (resin modified glass ionomer cement [RMGIC] with composite resin) can be used. In this case, Filtek Z350 composite resin was used with RMGIC as the liner base material. RMGIC is a good choice because of its biocompatibility, adhesion to calcified substrates (especially in cases of dentin sclerosis where traditional adhesion may underperform), and elastic modulus similar to dentin.[1314] Filtek z350 is used because it has better polish retention than a microfill, outstanding strength for anterior and posterior use, wide range of shades and opacities and improved fluorescence. This material is ideally used in Sandwich technique with glass ionomer resin material. Improvement in the final esthetics and better resolution of dentin hypersensitivity have been observed following such treatment.[15]

The result of this case indicates that while complete root coverage was not possible, nearly 50% of the denuded root surfaces could be covered with free gingival grafts in class III recession, contributing to the overall improvement in the periodontal health. The patient showed a statistically significant reduction in gingival recession between baseline and subsequent observation periods. The biocompatibility of the material added to the fact that the patient was followed monthly for prophylaxis, plaque control, and oral hygiene instructions may help to explain the improvement in gingival health observed during the follow-up period.

CONCLUSION

An interdisciplinary approach to treating cervical lesions will create the most biologically appropriate, stable and esthetic outcome. Soft tissue grafting is an integral part in the treatment of lesions that are caused due to lack of adequate attached gingiva and for root exposure associated with these lesions. A successful diagnosis with thorough patient history and careful observations and evaluations will give a satisfactory treatment outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest