Volume 78 • Number 6

Case Report
Periodontal Surgery and Glass Ionomer Restoration in the
Treatment of Gingival Recession Associated With a
Non-Carious Cervical Lesion: Report of Three Cases
Mauro Pedrine Santamaria,* Fabrı́cia Ferreira Suaid,* Francisco Humberto Nociti Jr.,*
Márcio Zaffalon Casati,* Antônio Wilson Sallum,* and Enilson Antônio Sallum*

Background: Buccal gingival recession is a preva-

A
s the caries prevalence is reduced in several
lent problem in populations with a high standard of populations, teeth are functional for longer
oral hygiene and is very often associated with a periods.1 This situation may expose the teeth
non-carious cervical lesion, complicating treatment. to conditions other than caries and, as a conse-
The purpose of this report is to show three cases trea- quence, different problems may develop. Gingival
ted by an integrated periodontal and restorative den- recession and non-carious cervical lesions are alter-
tistry approach. ations in soft and hard tissue, respectively, that seem
Methods: Three patients with Miller Class I gingi- to increase with age.2,3
val recessions associated with non-carious cervical Gingival recession is an apical shift of the gingival
lesions were enrolled for treatment. One patient re- margin with exposure of the root surface.4 It is a com-
ceived a coronally positioned flap and a resin-modified mon finding in populations with a high standard of oral
glass ionomer restoration, and two patients were treated hygiene and in periodontally untreated populations
with a coronally positioned flap, resin-modified glass with poor hygiene.2 Many factors have been proposed
ionomer restoration, and connective tissue graft. Prob- to influence the development of marginal tissue reces-
ing depth (PD), relative gingival recession (RGR), and sion, including plaque-induced inflammation, tooth-
clinical attachment level (CAL) were measured at brush trauma, tooth alignment, orthodontics, and
baseline and at 6 and 8 months after surgery. restorative procedures. The migration of the marginal
Results: After the healing period, all patients tissue to an apical position may lead to esthetic dam-
showed CAL gain and reduction in RGR. No differ- age, dentin hypersensitivity, root caries, and cervical
ence was observed on PDs compared to baseline. No wear.5
signs of gingival inflammation or bleeding on probing Non-carious cervical lesions and gingival recession
were seen. The patients were satisfied with the final are closely related to each other, in both etiologic fac-
esthetics and had no more dentin hypersensitivity. tors and therapeutic procedures.6 It has been reported
Conclusion: This report indicates that teeth with that, after examining 900 teeth with gingival reces-
Miller Class I gingival recessions associated with non- sion, no signs of the anatomic cemento-enamel junc-
carious cervical lesions can be successfully treated tion (CEJ) could be seen in about one-half of the
by an integrated periodontal and restorative dentistry examined teeth.7 In the great majority (>90%) of these
approach; however, longitudinal randomized con- teeth, cervical abrasion was associated with recession
trolled clinical trials must be performed to support of the marginal soft tissue. It can be speculated that
this approach. J Periodontol 2007;78:1146-1153. traumatic toothbrushing is the etiologic factor that af-
fected the cervical region of the tooth, initially causing
KEY WORDS
gingival recession followed by tooth abrasion.7
Cemento-enamel junction; gingival recession/ Despite this close relationship between these two
surgery; glass ionomer cement; surgical flap; phenomena, the literature shows different treatments
tooth abrasion. for hard tissue reconstruction, without much consid-
eration to the presence of gingival recession or the fi-
nal overall esthetic result. In some of these reports,8,9
gingivectomy was performed to allow isolation of the
non-carious cervical lesion and the restorative proce-
dure. Tissue excision procedures can alter the normal
* Department of Prosthodontics and Periodontics, Division of Periodontics,
School of Dentistry at Piracicaba, State University of Campinas, Campinas,
SP, Brazil. doi: 10.1902/jop.2007.060402

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position of the gingival zenith, leading to esthetic

damage. Optimal functional and esthetic results
may require combined application of periodontal
and restorative procedures.10
To our knowledge, there is no controlled clinical
trial in the literature focused on the simultaneous peri-
odontal and restorative procedures in the treatment of
gingival recession associated with a non-carious cer-
vical lesion. Some previous reports6,10,11 showed re-
storative and periodontal plastic surgery as isolated
procedures to achieve esthetic results. The combined
approach to treat this specific condition has not been
explored in the literature, mainly considering peri-
odontal parameters such as gingival health, stability
of gingival margin, and gain in clinical attachment
levels (CALs). Therefore, this report describes three Figure 1.
cases treated in the School of Dentistry at Piracicaba, Preoperative view of the canine and first premolar. Gingival recession
State University of Campinas (UNICAMP), during associated with a non-carious cervical lesion.
2005. The patients were treated with a coronally po-
sitioned flap, with or without a connective tissue graft
associated with a restoration of the non-carious cervi- disorders, and no further problems were found on ex-
cal lesion with resin-modified glass ionomer cement. amination as traumatic occlusion. After being in-
The procedures (surgery plus restoration) were per- formed of her problem and the alternatives to solve
formed in a single session. Moreover, this study dis- it, she gave consent to the periodontal restorative in-
cusses some local anatomic features related to tegrated procedure.
these procedures and to the final outcome. Under local anesthesia,i three horizontal incisions
were performed on the base of the papillae. The
CASE REPORTS horizontal incisions at the mesial aspect of the canine
Case 1 and distal aspect of the premolar were extended to the
A 34-year-old white female was referred to dental care adjacent teeth, avoiding touching them. Vertical ob-
presenting dentin hypersensitivity on her maxillary lique incisions were made, passing through the muco-
right canine and first premolar. Clinical examination gingival junction. A full-thickness flap was elevated
revealed Miller Class I gingival recessions associated up to 3 mm apically to the bone crest, and a partial-
with non-carious cervical lesions in the maxillary right thickness flap was raised (Fig. 2). After observation
canine and first premolar and loss of the anatomic of the cervical lesions, rubber dam¶ isolation was per-
CEJ in both teeth (Fig. 1). The following clinical pa- formed (Fig. 3). Restoration was performed with
rameters were evaluated: probing depth (PD), as- resin-modified glass ionomer cement,# following the
sessed as the distance from the gingival margin to manufacturer’s instructions (Fig. 4). Special care
the apical end of the gingival sulcus measured with was taken to avoid an excessively convex restoration
a manual periodontal probe;† non-carious cervical le- surface, which might impair stability of the gingival
sion height (CLH), measured as the distance between margin in the coronal position. After polishing with
the coronal and apical margins of the non-carious cer- a finishing bur** and application of finishing gloss,
vical lesion; relative gingival recession (RGR), mea- the rubber dam was removed, and a connective tissue
sured as the distance from the gingival margin to graft was placed. Sutures†† were made, pulling the
the incisal border of the tooth; and CAL, measured gingival margin as coronally as possible, covering
as PD + RGR. The RGR and CLH were measured with the entire restoration (Fig. 5).
a pair of dividers‡ and a digital caliper§ with 0.01 pre- Post-surgical care included an analgesic medica-
cision for achievement of reliable measurements. The tion (500 mg sodium dipyrone‡‡) for 3 days and in-
PD was 1 mm at the buccal aspect of both teeth. The structions to avoid toothbrushing around the surgical
RGR was 11.37 mm for the canine and 9.30 mm for
† Hu-Friedy, Jacarepagua, RJ, Brazil.
the premolar. The CLH was 2.93 mm for the canine ‡ n 030-395, Dentaurum, Ispringen, Germany.
and 2.01 mm for the premolar. No signs of bleeding § Absolute, Mitutoyo Sul Americana, Suzano, SP, Brazil.
i Alphacaine, DFL, Rio de Janeiro, RJ, Brazil.
on probing and inflammation were observed. The clin- ¶ SS White, Rio de Janeiro, RJ, Brazil.
ical features of the cervical lesions seemed to be a # Vitremer, 3M ESPE, St. Paul, MN.
** KG Sorensen 9803FF, São Paulo, SP, Brazil.
consequence of the abrasion process. The patient †† 6.0 Polyglactin 910 (Vicryl), Ethicon, São José dos Campos, SP, Brazil.
denied parafunctional habits, acidic diet, and eating ‡‡ Proderma Farmácia de Manipulac xão, Piracicaba, SP, Brazil.

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Root Coverage on Restored Root Surface Volume 78 • Number 6

Figure 2.
The flap was raised.
Figure 4.
The restoration of the non-carious cervical lesion with a resin glass
ionomer material.

Figure 3.
Isolation of the operative field. Figure 5.
Sutured flap.

site for 4 weeks. During this period, plaque control

was performed by rinsing with a 0.12% chlorhexidine gival margin was in a coronal position compared to
digluconate solution§§ twice a day. After this period, the initial situation (Fig. 6).
gentle toothbrushing with a soft-bristle toothbrush Case 2
was allowed. Sutures were removed after 1 week. A 39-year-old white male was referred for a root cov-
The patient was enrolled in a periodontal maintenance erage procedure on the maxillary left canine. Clinical
program (professional plaque control) weekly for the examination revealed a 3.83-mm CLH affecting both
first 4 weeks and then monthly for 5 months. After the the crown and root of this tooth associated with Miller
6-month period, the patient reported resolution of Class I gingival recession (Fig. 7). The depth of the
the dentin hypersensitivity and was satisfied with non-carious cervical lesion, which is the distance be-
the esthetics of her smile. Clinical parameters were tween the bottom of the cervical lesion and the most
taken and showed gingival health, with no signs of in- buccal point of the incisal border of the cervical lesion,
flammation or bleeding on probing. PDs remained was 2.11 mm. This condition would create a big ‘‘dead
the same, namely 1 mm, and the site showed gain space’’ between the connective tissue and the tooth if
in CAL of 1.97 mm for the canine and 1.12 mm for
the premolar. This gain in CAL indicates that the gin- §§ Periogard, Colgate, São Paulo, SP, Brazil.

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J Periodontol • June 2007 Santamaria, Suaid, Nociti, Casati, Sallum, Sallum

Figure 6.
Clinical view after 6 months.

Figure 8.
Sutured flap.

patient presented a 2.2-mm gain in the CAL, and the

same initial PD of 1 mm was maintained after this
period. These measurements indicate that part of
the restoration is located subgingivally. No signs of
gingival inflammation or bleeding on probing were
noted. The patient was satisfied with his final esthetics
(Fig. 9).
Case 3
A 52-year-old white male was referred for a root
coverage procedure on the maxillary right canine.
Clinical examination revealed shallow cervical wear
associated with a Miller Class I gingival recession
and loss of the anatomic CEJ (Fig. 10). The distance
between the enamel margin and the gingival margin
was 2.3 mm and the PD was 1 mm at the buccal aspect
Figure 7. of the tooth. No signs of gingival inflammation or bleed-
Preoperative view. Note that the non-carious cervical lesion is affecting ing on probing were observed. A coronally positioned
both the crown and root of the tooth. flap associated with a resin-modified glass ionomer
restoration and a connective tissue graft was the se-
lected treatment approach (Fig. 11). Sutures were
a coronally positioned flap was done. If the restorative placed, pulling the gingival margin as coronally as
procedure was performed solely, the marginal tissue possible (Fig. 12).
would remain at the same position, leading to a very The post-surgical care instructions for this patient
high crown and esthetic damage. Because of these were the same as in the previous cases. After the
limitations in applying each procedure alone, the 6-month period, the patient presented a 1.8 mm gain
integrated procedure was selected. A coronally po- in the CAL, and the same initial PD of 1 mm was main-
sitioned flap was performed, and a resin-modified tained. These measurements indicate that most of the
glass ionomer restoration was made following the restoration is in a subgingival location. No signs of gin-
manufacturer’s instructions. After that, suturesii were gival inflammation or bleeding on probing were noted,
made, pulling the gingival margin as coronally as pos- and the patient was happy with his esthetics (Fig. 13).
sible (Fig. 8).
The post-surgical care instructions for this patient
were the same as in the first case. After 8 months, this ii Silk Suture 4.0, Ethicon.

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Root Coverage on Restored Root Surface Volume 78 • Number 6

Figure 11.
Connective tissue graft in position.

Figure 9.
Clinical outcome after 8 months.

Figure 12.
Sutured flap.

Figure 10.
Preoperative view. habits, and signs of traumatic occlusion. The treatment
success and longevity may depend on the identification
and elimination of these etiologic factors.
The clinical parameters of all patients at baseline The presence of Miller Class I or II gingival reces-
and post-surgical evaluation are shown in Table 1. sions associated with non-carious cervical lesions
may require periodontal surgery combined with re-
DISCUSSION storative treatment. Selection of the treatment plan
The first treatment step of this clinical problem should depends on the local anatomic characteristics, such
be the elimination or control of all potential etiologic fac- as the height and depth of the non-carious cervical le-
tors associated with the occurrence of gingival reces- sion, extent of the crown and root areas affected by the
sion and non-carious cervical lesions. Medical history non-carious cervical lesion, presence and height of
and a detailed clinical examination are important for gingival recession, presence of keratinized tissue ap-
identification of gingival inflammation, periodontal dis- ical to the defect, and esthetic expectations of the pa-
ease, traumatic toothbrushing, excessive consumption tient. Resolution of both gingival and dental defects is
of acidic beverages, dietary disorders, parafunctional one advantage of the integrated approach.

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On the other hand, if the surgical procedure for root

coverage is individually performed, the coronal por-
tion of the non-carious cervical lesion may not be cov-
ered by the periodontal flap after the healing period,
giving the impression that the procedure was unsuc-
cessful.7 If the exposed coronal portion of the non-
carious cervical lesion is maintained, there may be
persistence of dentin hypersensitivity. Moreover, the
coronally positioned flap might be individually per-
formed in these cases if the non-carious cervical le-
sion is up to 1.0 to 1.5 mm deep. If the non-carious
cervical lesion is deep, a ‘‘dead space’’ may be pres-
ent, impairing good adaptation of the connective and
epithelial tissues of the flap to the tooth surface. Also,
elimination of the concavity of the lesion by root scal-
ing with hand instruments or diamond finishing burs in
high speed to allow better adaptation of the flap on the
Figure 13. root may not be possible, depending on the depth of
Clinical outcome after 6 months. the non-carious cervical lesion and amount of intact
tooth structure that must be removed for achievement
of such a smooth surface.
When only the non-carious cervical lesion is treated Loss of the CEJ is frequently observed in these
by a restorative procedure, the position of the gingival cases because the non-carious cervical lesion affects
zenith is kept more apically because of the persistence both the crown and root of the tooth. Thus, the amount
of the gingival recession, which would lead to a longer of gingival recession may not be precisely measured;
tooth and consequently to a possible esthetic dishar- however, it should probably be smaller than the non-
mony. Moreover, it was shown that 37.0% of the apical carious CLH. This might explain why a small portion of
margin of non-carious cervical lesions are located at the restorations in these cases was not covered and
the same level as the gingival margin and 32.5% are remained supragingivally positioned after the healing
located subgingivally.12 The location of the apical period. This uncovered portion of the restorations
margin of the non-carious cervical lesion in the gingi- probably represents the part of the tooth crown af-
val margin may complicate or even prevent the use of fected by the non-carious cervical lesion.
rubber dam isolation, which may impair the adhesion In all cases of the present study, the apical margin
and success of bonded restorations.13 This difficulty of the non-carious cervical lesion was located at the
to achieve proper isolation of the operative field, same level as the gingival margin. Considering this
which is essential for the restorative procedure, may fact, the reduction of RGR in case 1 was 1.97 mm
lead the clinician to perform gingivectomy, which is for the canine and 1.12 mm for the premolar, indicat-
commonly used for that purpose. However, this ing that the same extent of the restoration of each
may lead to gingival recession, altering the position tooth is subgingivally positioned (uncovered supra-
of the gingival zenith. gingival portion of restorations was 0.93 mm for the

Table 1.
Clinical Parameters (in mm) at Baseline and After Surgery

Baseline Postoperative

RGR Reduction CAL Gain

PD RGR CAL CLH PD RGR (postbaseline) CAL (postbaseline)

Case 1
Canine 1 11.37 12.37 2.93 1 9.4 1.97 10.4 +1.97
Premolar 1 9.3 10.3 2.01 1 8.18 1.12 9.18 +1.12

Case 2 1 14.04 15.04 3.83 1 11.84 2.2 12.84 +2.2

Case 3 1 13.08 14.08 2.3 1 11.34 1.74 12.34 +1.74

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Root Coverage on Restored Root Surface Volume 78 • Number 6

canine and 0.89 mm for the premolar). In cases 2 and Dentistry, Prosthodontics, Temporomandibular Joint,
3, 2.20 and 1.74 mm of the restorations were covered Implantology, Oral Surgery and Geriatric Dentistry,
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2. Löe H, Anerud A, Boysen H. The natural history of
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term report that must be confirmed by longitudinal tol 1996;1:671-701.
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2001;27:97-120.
the healing pattern after this type of treatment. How-
6. Toffenetti F, Vanini L, Tammaro S. Gingival recessions
ever, a repair response (epithelium and/or connective and noncarious cervical lesions: A soft and hard tissue
tissue adaptation) may occur.14 challenge. J Esthet Dent 1998;10:208-220.
Selection of the resin-modified glass ionomer ce- 7. Zucchelli G, Testori T, De Sanctis M. Clinical and
ment as the restorative material was based on pre- anatomical factors limiting treatment outcomes of gin-
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a gingival recession associated with a root resorption 10. Terry DA, McGuire MK, McLaren E, Fulton R, Swift EJ
Jr. Perioesthetic approach to the diagnosis and treat-
cavity with a connective tissue graft and a resin glass ment of carious and noncarious cervical lesions: Part
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tions of the presence of connective tissue and epithe- 11. Terry DA, McGuire MK, McLaren E, Fulton R, Swift EJ
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the resin-modified glass ionomer cement presents ment of carious and noncarious cervical lesions: Part I.
J Esthet Restor Dent 2003;15:217-232.
better retention in Class V restorations compared to 12. Miller N, Penaud J, Ambrosini P, Bisson-Boutelliez C,
composite resin restorations.16 Briancon S. Analysis of etiologic factors and peri-
It is important to note that there are limitations to odontal conditions involved with 309 abfractions.
the periodontal surgery for root coverage. Gingival J Clin Periodontol 2003;30:828-832.
thickness,18 flap tension,19 adjacent papilla height,20 13. Lambrechts P, Van Meerbeek B, Perdigao J, Gladys S,
Braem M, Vanherle G. Restorative therapy for erosive
and post-surgical position of the gingival margin21 lesions. Eur J Oral Sci 1996;104:229-240.
may also interfere when a periodontal plastic surgery 14. Dragoo MR. Resin-ionomer and hybrid-ionomer ce-
is performed on restored root. Therefore, this com- ments: Part II, human clinical and histologic wound
bined approach should only be performed where local healing responses in specific periodontal lesions. Int J
anatomic characteristics allow a favorable prognosis. Periodontics Restorative Dent 1997;17:75-87.
15. Dragoo MR. Resin-ionomer and hybrid-ionomer ce-
Periodontal surgery combined with the restorative ments: Part I. Comparison of three materials for the
procedure provides resolution of both the gingival de- treatment of subgingival root lesions. Int J Periodontics
fect and the cervical wear of the tooth in a single ses- Restorative Dent 1996;16:594-601.
sion. Even though some authors10,22 have suggested 16. Brackett WW, Dib A, Brackett MG, Reyes AA, Estrada
that the presence of the restorative material on the BE. Two-year clinical performance of class V resin-
modified glass ionomer and resin composite restora-
root surface may interfere with the success of the root tion. Oper Dent 2003;28:477-481.
coverage, these cases indicate that the presence of 17. Alkan A, Keskiner I, Yuzbasioglu E. Connective tissue
the restoration does not impair the gingival margin grafting on resin ionomer in localized gingival reces-
stability during the observation period of this report. sion. J Periodontol 2006;77:1446-1451.
However, further studies are needed for evaluation 18. Baldi C, Pini-Prato G, Pagliaro U, et al. Coronally
advanced flap procedure for root coverage. Is flap
of the amount of root coverage achieved on previ- thickness a relevant predictor to achieve root cover-
ously restored roots and its maintenance over time. age? A 19-case series. J Periodontol 1999;70:1077-1084.
19. Pini Prato G, Pagliaro U, Baldi C, et al. Coronally
advanced flap procedure for root coverage. Flap
with tension versus flap without tension: A randomized
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J Periodontol • June 2007 Santamaria, Suaid, Nociti, Casati, Sallum, Sallum

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1153