The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
649
Treatment of Noncarious Cervical Lesions by a Subepithelial Connective Tissue Graft Versus a Composite Resin Restoration Martin Leybovich, DDS, MSD1 Nabil F. Bissada, DDS, MSD2 Sorin Teich, DMD, MBA3 Catherine A. Demko, MS, PhD4 Paul A. Ricchetti, DDS, MScD5 This study compared two treatments for mild noncarious cervical lesions (NCCLs): a subepithelial connective tissue graft (CTG) versus a Class V composite resin restoration (CRR). Twenty-six sites with NCCLs were randomly assigned to be treated by CTG or CRR. Periodontal health parameters and dentinal hypersensitivity (DH) were recorded at baseline and 3 months postoperatively. Esthetics was also evaluated at 3 months. Results showed a significant improvement in all periodontal health parameters in the CTG treatment. The CTG treatment attained a mean 82% defect coverage with 75% of sites achieving complete coverage. Patients rated the CTG treatment to be significantly more esthetic (P = .03), while a clinician panel did not see an esthetic difference (P = .86). There was no difference in DH reduction between the two treatments (P = .81). In conclusion, the CTG treatment is superior to the CRR treatment for NCCLs based on periodontal health parameters. From a patient point of view, the CTG is the more esthetic treatment. (Int J Periodontics Restorative Dent 2014;34:649–654. doi: 10.11607/prd.2033)
Private Practice, Baltimore, MD; Resident, Department of Periodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA. 2Professor, Chairman, and Program Director, Department of Periodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA. 3Assistant Dean of Clinical Operations and Associate Professor, Department of Comprehensive Care, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA. 4Associate Professor, Department of Community Dentistry, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA. 5Private Practice, Mayfield Heights, OH; Associate Clinical Professor, Department of Periodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA. 1
Correspondence to: Dr Nabil F. Bissada, Department of Periodontics, School of Dental Medicine, Case Western Reserve University, 2124 Cornell Road, Cleveland, OH 44106-4905, USA; email: [email protected]. ©2014 by Quintessence Publishing Co Inc.
In the current era of advanced den tal biomimetic materials and tech nologies, esthetic dentistry has become a commonly used term. The clinician’s role has evolved from one of simply providing treatment to repair a dental problem into one that incorporates the overall facial appearance of the individual. The specialty of periodontics has under taken an analogous role by ensur ing that patients’ periodontal health is incorporated into their overall facial appearance. At the forefront of esthetic periodontal treatment is the treatment of gingival recession. One way that gingival recession may present itself is in conjunction with a noncarious cervical lesion (NCCL). NCCLs are hard tissue le sions near the gingival margin of teeth that are not etiologically based on dental plaque.1 Rather, they can be caused by a triad of abrasion, erosion, or abfraction.2 NCCLs are associated with the cervical region of a tooth, specifi cally in the region of the cemento enamel junction (CEJ). Treatment is contingent on the extent of gin gival recession, the lesion area, and its relationship to the CEJ.3 When
Volume 34, Number 5, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
650 the lesion presents coronal to the CEJ, restorative intervention may be incorporated into the treatment. When NCCLs are milder, present ing strictly apical to the CEJ, then periodontal or restorative treatment or a combination of the two may be rendered.4,5 Although both periodontal plastic surgery and a restorative ap proach to treating gingival recession have advantages and disadvantag es, historically the more common treatment has been the latter.3 No studies have compared the success of the two treatment modalities. Since periodontal plastic surgery and restorative approaches are both utilized for the treatment of mild NCCLs, this prospective compara tive study was undertaken to deter mine which of the two approaches provides a better outcome for treat ing NCCLs.
Method and materials Institutional review board approval for this prospective randomized clinical trial was received from University Hospitals Case Medi cal Center, Case Western Reserve University, Cleveland, Ohio, USA. Nine patients with 26 sites were recruited into this prospective ran domized clinical trial. Thirteen sites were treated with a subepithelial connective tissue graft (CTG), and 13 sites were treated with a Class V composite resin restoration (CRR). Selection of sites was based on the following inclusion criteria: NCCLs apical to the CEJ, Miller Class I or II gingival recession defects, sites
limited to maxillary nonmolar teeth, and patients ages ≥ 18 years old. Patients were excluded based on the following criteria: NCCLs ex tending coronal to the CEJ, Miller Class III or IV recession defects, mandibular sites, maxillary sites dis tal to the second premolars, previ ously treated noncarious lesions by either periodontal plastic surgery or restorative procedures, patients younger than 18 years old, smokers, pregnant patients, immunocompro mised patients, or any disease or condition that would preclude pa tients from undergoing periodontal surgery. Following selection of sites, pa tients signed a consent form to par ticipate in this study. Each patient had one site randomly assigned to be treated by either a CTG or CRR. The following periodontal clinical parameters were recorded by a sin gle calibrated clinician (ML) at base line and 3 months postoperatively: gingival index (GI), plaque index (PI), probing depths (PDs) at six sites per tooth, percentage bleeding on probing (BOP) at six sites per tooth, gingival recession (GR) on the labial/ buccal surface, clinical attachment levels (CAL), and keratinized gingiva (KG). Using an air-water syringe, air was applied to the buccal surface of the NCCL, and the patient recorded the severity of dentinal hypersensi tivity (DH) on a visual analog scale (VAS) from 0 to 10, where 0 referred to no sensitivity and 10 referred to severe sensitivity. Using digital photography (Canon EOS Digital Rebel T1i SLR Camera, Canon EF 100mm f/2.8 USM Macro Auto Fo cus Lens, and Canon Macro Ring
Lite MR-14EX with E-TTL; Canon USA), photos were taken of the se lected sites. Preoperatively, sites underwent dental prophylaxis and occlusal adjustment as necessary. Sites randomized to receive a CRR were treated by one clinician (ST) using the following protocol: sites were prepared conservative ly, and a retraction cord (Ultrapak, Ultradent) was utilized for ad equate submarginal visualiza tion and hemostasis. A matching shade of composite was chosen, and the tooth was restored, fin ished, and polished (TPH3 Micro Matrix Restorative composite, Dentsply Caulk). Sites randomized to be treated with a CTG were also treated by one clinician (ML) utilizing the technique originally described by Langer and Langer.6 Patients were prescribed the fol lowing medications postoperative ly: amoxicillin 500 mg, 21 tabs to be taken as 1 tab three times daily until finished; ibuprofen 800 mg, 28 tabs to be taken as 1 tab every 8 hours as needed for pain; and a methylprednisolone pack as di rected. Patients were scheduled for follow-up at 2 weeks, 6 weeks, and 3 months. At 3 months post operatively, patients were instruct ed to score the esthetics of the two sites treated from a scale of 0 to 10, where 0 was not esthetic and 10 was most esthetic. Postop erative photographs were taken, and four clinicians not involved in the study, two experienced perio dontists and two prosthodontists, were asked to evaluate the esthet ics of the treated sites using the same scale of 0 to 10. Using an
The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
651 air-water syringe, air was applied to the sites, and the patient recorded the degree of DH on a VAS. All data were analyzed statistically with the Wilcoxon signed rank test with sta tistical significance at P ≤ .05.
Results Of the nine patients with 26 sites that were treated in this study, one patient did not return for his final postoperative appointment, and thus, eight patients with 24 sites were included in the final data col lection: 12 sites that underwent a subepithelial CTG and 12 sites that underwent a Class V CRR. When comparing the change in periodontal clinical parameters, there was a statistically significant improvement in GI, PI, BOP, GR, KG, and CAL (Table 1). There was no statistically significant improve ment in PD at six sites per tooth, yet the data were close to significant (P = .06). The percentage of mean root coverage 3 months after sur gery was 82%, with 75% achieving complete coverage. In the patients’ own evaluations of final esthetics using a scale of 0 to 10, there were statistically sig nificant higher esthetic scores given to sites with the CTG treatment in comparison to the CRR treatment (means: CTG = 7.9 ± 1.7, CRR = 5.5 ± 2.5, P = .03). The two periodon tists and two prosthodontists who scored the esthetics did not find a statistical difference in esthetics be tween the two treatments (means: CTG = 6.3 ± 1.3, CRR = 6.4 ± 1.8, P = .86).
Table 1 Change in study measures within treatments and difference between treatments Measures
CTG (mean ± SD)
CRR (mean ± SD)
Difference* (mean ± SD)
P value†
GI
–0.38 ± 0.27
0.63 ± 0.44
–1.01 ± 0.47
.002
BOP (%)
–0.21 ± 0.22
0.18 ± 0.31
–0.39 ± 0.27
.007
CAL (mm)
–0.60 ± 0.49
0.04 ± 0.41
–0.64 ± 0.62
.005
PD (mm)
–0.25 ± 0.43
0.04 ± 0.41
–0.29 ± 0.54
.06
GR (mm)
–2.04 ± 0.96
0.08 ± 0.51
–2.12 ± 1.09
.003
PI
–0.05 ± 0.62
0.35 ± 0.81
–0.40 ± 0.50
.02
KG
0.92 ± 1.0
–0.33 ± 1.07
1.25 ± 1.14
.008
DH
–1.25 ± 3.74
–1.5 ± 3.09
0.25 ± 2.91
.77
*Treatment differences = change in CTG – change in CRR; negative values favor the CTG treatment for all measures except KG, for which a positive number favors CTG treatment. † Based on Wilcoxon signed rank test. Values in bold are statistically significant at P < .05.
a
b
c
d
Fig 1 (a) Preoperative and (b) 3-month postoperative images of CRR treatment of an NCCL on a maxillary right central incisor. (c) Preoperative and (d) 3-month postoperative images of subepithelial CTG treatment of an NCCL on a maxillary left central incisor.
The mean change in DH be tween baseline and 3 months did not reach a statistically significant difference between the two treat ments (P = .77; see Table 1). In this particular outcome criteria, the authors also sought to analyze the DH for matched sites that attained 100% root coverage, but there was still no statistical difference (means: CTG = –1.89 ± 3.3, CRR = –1.22 ± 2.5, P = .55). Comparing only sites with severe DH (VAS score ≥ 6 at baseline), there was a statistically significant improvement in DH in patients in the CTG treatment from baseline to 3 months postopera
tively (means: initial = 7.83 ± 1.3, final = 4.0 ± 2.5, P = .03). When comparing analogous sites in the CRR treatment, there was no sta tistically significant improvement in DH (means: initial = 7.0 ± 2.0, final = 3.25 ± 3.5, P = .25).
Discussion This study evaluated the periodontal health, esthetics, and dentinal hy persensitivity of NCCLs treated by a subepithelial CTG versus a Class V CRR (Fig 1). Although there have been studies that have taken into
Volume 34, Number 5, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
652 account the ability to predictably perform root coverage procedures on already restored NCCLs,5 this is the first study that was able to iden tify mild NCCLs that could be treat ed by either of the two treatments alone and attempted to determine which treatment is more favorable. There was a significant differ ence in the change of GI, PI, and BOP in the CTG treatment in com parison to the CRR treatment. The change can be attributed to the elimination of the plaque-retentive environment of the NCCLs, whereas there was an impingement of the re storative material on the gingival sul cus in the CRR treatment sites. In the latter, irregular restorative margins, irregular surface of the restoration, or overcontouring of the restoration may have created a more plaqueretentive environment and increased gingival inflammation. There was a statistically signifi cant difference in the mean change of gingival recession measurements between both treatments. The mean root coverage attained in the CTG treatment was 82%. One hundred percent root coverage was attained at 75% of sites (9 of 12). The sub epithelial CTG is the gold standard treatment for root coverage pro cedures according to a systematic review by Chambrone et al.7 The range of mean root coverage in Chambrone’s review was 64.5% to 97.3%. The range for complete root coverage was 8.6% to 96.1%. In a systematic review by Oates et al,8 the mean root coverage was 77.9%, and 37.4% of sites attained 100% root coverage. The American Academy of Periodontology informational pa
per on oral reconstructive and cor rective considerations in periodontal therapy reported that the mean root coverage was 84% for connective tissue graft techniques.9 In addition, Greenwell and Bissada reported a mean root coverage of 82%.10 The mean root coverage of 82% and the complete root coverage of 75% in this study are comparable to the abovementioned reviews. This study indicates that patients believe that the CTG treatment is a more esthetic treatment than the CRR treatment. When esthetics was scored by a panel of two periodon tists and two prosthodontists, there was no statistical difference between the two treatments. It is possible that periodontists and prosthodontists were more critical in judging the es thetic outcome than the laypersons; or in the eyes of a clinician, mild NCCLs may not pose an esthetically significant difference when compar ing these two treatments. The con cept of “minimal clinically important difference (MCID)” as introduced by Jaeschke et al11 has much signifi cance on these findings. Jaeschke et al defined MCID as the “smallest difference in score in the domain of interest which patients perceive as beneficial and which would man date . . . a change in the patient’s management.”11 Therefore, in the present study, although the panel of clinicians did not perceive an es thetic difference between the two treatments, since patients believed that the CTG treatment was more esthetically beneficial, from an es thetic point of view, the CTG treat ment should be the treatment of choice for mild NCCLs.
At the completion of the study, it was decided to utilize the root coverage esthetic score (RES) as introduced by Cairo et al12 to score the esthetics of the NCCLs for the CTG treatment. The RES takes into account not only the root coverage, but also the gingival margin align ment (scalloped or flat), tissue tex ture (scars or keloids), mucogingival junction alignment (continuous with adjacent teeth or not), and tissue color (color integration with adja cent tissue). Since root coverage is the primary goal, it is given the most weight, where complete root coverage has a score of 6, partial root coverage has a score of 3, and no coverage has a score of 0. The rest of the categories have a score of either 0 or 1 (Fig 2). In the pres ent study, the mean RES was 7.6, which is within range of the Cairo et al mean RES of 7.8. Therefore, this study clearly supports the con clusion of Cairo et al that although root coverage is the most important outcome parameter for soft tissue grafting, emphasis should also be placed on the overall esthetics of the teeth being covered. It may be difficult to objec tively compare the esthetics of the two treatments. In fact, one may contend that the composite res toration is not esthetic at all but rather cosmetic. Touyz et al13 took the meanings of the words esthetic and cosmetic and applied them to dentistry: “cosmetic dentistry re fers to a result that does not neces sarily function ideally and does not always emulate the pristine state of natural tissue.” Esthetic dentistry, however, “incorporates acceptable
The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
653 biologics for long-term survival, and mimics the pristine state of the natural tissue.” Therefore, it would seem that a subepithe lial CTG for NCCLs is an esthetic treatment since it mimics the pris tine state of the natural dentition, whereas a Class V composite res toration for NCCLs is a cosmetic treatment since it does not return the gingiva to its physiologic and harmonious state within the con fines of the tooth (Figs 3 and 4). Accordingly, when 100% root cov erage is attained after periodontal plastic surgery procedures, even if there is a failure to meet the es thetic criteria in the RES of Cairo et al, at the very least it may be considered cosmetic. Based on this concept, one may also postulate that the proper term when com paring the two treatments is not a comparison of esthetics nor a com parison of cosmetics, rather simply a comparison of appearance. When discussing DH, it should be pointed out that this is the first study that compares root cover age procedures to restorative pro cedures with DH as an outcome measure. Although there was no statistical difference when com paring DH between the two treat ments, there was a significant difference in DH when comparing more severe DH sites. From a clini cally relevant standpoint, however, both treatments were able to low er DH significantly (mean change: CTG = 3.83, CRR = 3.75). Although systematic reviews in the periodon tal literature state that DH can be decreased with root coverage pro cedures,8 there are very few clinical
Root coverage esthetic score (RES) Esthetic criteria Root coverage
RES system
Score
No coverage = 0 Partial coverage = 3 Complete coverage = 6
6
Gingival margin Flat gingival margin = 0 alignment Scalloped gingival margin = 1 Texture
Scar or keloid formation = 0 No scar or keloid formation = 1
Mucogingival junction alignment
Not aligned with adjacent teeth = 0 Aligned with adjacent teeth = 1
Tissue color match
No tissue color match = 0 Tissue color match = 1
1 0 0 RES = 8
1
Fig 2 Calculation of RES for a maxillary right first premolar.
a
b
a
b
Fig 3 (a) Three-month postoperative image of a maxillary left first premolar treated with CRR. Note the well-blended restoration and the appearance of a longer tooth. (b) Three-month postoperative image of a maxillary right first premolar treated with a subepithelial CTG. Note scar tissue formation and complete root coverage.
Fig 4 (a) Three-month postoperative image of a maxillary right lateral incisor treated with CRR. Note the well-blended restoration yet the appearance of a long tooth with rolled gingival margins. (b) Three-month postoperative image of a maxillary left lateral incisor treated with a subepithelial CTG. Note the well-blended keratinized tissue texture and color, which restores the natural appearance.
studies that have specifically fo cused on root coverage and DH.14 It is noteworthy that long-term studies on CTG have shown stabil ity with minimal relapse,15 whereas Class V CRRs have a tendency to debond and become discolored over time.16 It is suggested for fur ther research to evaluate the impact of these characteristics on a larger scale with a longer follow-up.
Conclusions The results of the present study in dicate that a subepithelial CTG is a superior treatment option com pared with a Class V CRR for mild NCCLs based on periodontal health parameters. From a patient point of view, the subepithelial connective tissue graft is a more esthetic treat ment. Therefore, when esthetically
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654 demanding patients present with a NCCL, appropriate evidence-based guidelines should be provided to enable them to choose the treat ment that suits their esthetic re quirements even when there may not be a discernible difference in the clinicians’ eyes.
Acknowledgments The authors reported no conflicts of interest related to this study.
References 1. Summit JB, Robbins JW, Hilton TJ, Schwartz RS. Fundamentals of Opera tive Dentistry. 3rd ed. Chicago: Quintes sence, 2006. 2. Grippo JO, Simring M, Coleman TA. Ab fraction, abrasion, biocorrosion, and the enigma of noncarious cervical lesions: A 20-year perspective. J Esthet Restor Dent 2012;24:10–23. 3. Terry DA, McGuire MK, McLaren E, Fulton R, Swift EJ. Perioesthetic approach to the diagnosis and treatment of carious and noncarious cervical lesions: Part I. J Esthet Restor Dent 2003;15:217–232.
4. Pini Prato G, Tinti C, Cortellini P, Mag nani C, Clauser C. Periodontal re generative therapy with coverage of previously restored root surfaces: Case reports. Int J Periodontics Restorative Dent 1992;12:451–461. 5. Thanik SD, Bissada NF. Clinical study of connective tissue grafts for root coverage on teeth with cervical lesions with and without restoration [abstract 109]. J Dent Res 1999;78(special issue):119. 6. Langer B, Langer L. Subepithelial connec tive tissue graft technique for root cover age. J Periodontol 1985;56:715–720. 7. Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA. Can subepithelial connective tis sue grafts be considered the gold stan dard procedure in the treatment of Miller Class I and II recession-type defects? J Dent 2008;36:659–671. 8. Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of gingival recession. A systematic review. Ann Periodontol 2003;8:303–320. 9. Greenwell H, Fiorellini J, Giannobile W, et al; Research, Science and Therapy Com mittee. Oral reconstructive and corrective considerations in periodontal therapy. J Periodontol 2005;76:1588–1600. 10. Greenwell H, Bissada NF, Henderson RD, Dodge JR. The deceptive nature of root coverage results. J Periodontol 2000; 71:1327–1337.
11. Jaeschke R, Singer J, Guyatt GH. Mea surement of health status: Ascertaining the minimal clinically important difference. Control Clin Trials 1989;10:407–415. 12. Cairo F, Rotundo R, Miller PD, Pini Prato GP. Root coverage esthetic score: A sys tem to evaluate the esthetic outcome of the treatment of gingival recession through evaluation of clinical cases. J Periodontol 2009;80:705–710. 13. Touyz LZ, Raviv E, Harel-Raviv M. Cos metic or esthetic dentistry? Quintessence Int 1999;30:227–233. 14. Douglas de Oliveira DW, Marques DP, Aguiar-Cantuária IC, Flecha OD, Gon çalves PF. Effect of surgical defect cov erage on cervical dentin hypersensitivity and quality of life. J Periodontol 2013;84: 768–775. 15. Cortellini P, Prato GP. Coronally ad vanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience. Periodontology 2000 2012; 59:158–184. 16. Peumans M, Kanumilli P, De Munck J, Van Landuyt K, Lambrechts K, Van Meerbeek B. Clinical effectiveness of contemporary adhesives: A systematic review of cur rent clinical trials. Dent Mater 2005;21: 864–881.
The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
649
Treatment of Noncarious Cervical Lesions by a Subepithelial Connective Tissue Graft Versus a Composite Resin Restoration Martin Leybovich, DDS, MSD1 Nabil F. Bissada, DDS, MSD2 Sorin Teich, DMD, MBA3 Catherine A. Demko, MS, PhD4 Paul A. Ricchetti, DDS, MScD5 This study compared two treatments for mild noncarious cervical lesions (NCCLs): a subepithelial connective tissue graft (CTG) versus a Class V composite resin restoration (CRR). Twenty-six sites with NCCLs were randomly assigned to be treated by CTG or CRR. Periodontal health parameters and dentinal hypersensitivity (DH) were recorded at baseline and 3 months postoperatively. Esthetics was also evaluated at 3 months. Results showed a significant improvement in all periodontal health parameters in the CTG treatment. The CTG treatment attained a mean 82% defect coverage with 75% of sites achieving complete coverage. Patients rated the CTG treatment to be significantly more esthetic (P = .03), while a clinician panel did not see an esthetic difference (P = .86). There was no difference in DH reduction between the two treatments (P = .81). In conclusion, the CTG treatment is superior to the CRR treatment for NCCLs based on periodontal health parameters. From a patient point of view, the CTG is the more esthetic treatment. (Int J Periodontics Restorative Dent 2014;34:649–654. doi: 10.11607/prd.2033)
Private Practice, Baltimore, MD; Resident, Department of Periodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA. 2Professor, Chairman, and Program Director, Department of Periodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA. 3Assistant Dean of Clinical Operations and Associate Professor, Department of Comprehensive Care, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA. 4Associate Professor, Department of Community Dentistry, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA. 5Private Practice, Mayfield Heights, OH; Associate Clinical Professor, Department of Periodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA. 1
Correspondence to: Dr Nabil F. Bissada, Department of Periodontics, School of Dental Medicine, Case Western Reserve University, 2124 Cornell Road, Cleveland, OH 44106-4905, USA; email: [email protected]. ©2014 by Quintessence Publishing Co Inc.
In the current era of advanced den tal biomimetic materials and tech nologies, esthetic dentistry has become a commonly used term. The clinician’s role has evolved from one of simply providing treatment to repair a dental problem into one that incorporates the overall facial appearance of the individual. The specialty of periodontics has under taken an analogous role by ensur ing that patients’ periodontal health is incorporated into their overall facial appearance. At the forefront of esthetic periodontal treatment is the treatment of gingival recession. One way that gingival recession may present itself is in conjunction with a noncarious cervical lesion (NCCL). NCCLs are hard tissue le sions near the gingival margin of teeth that are not etiologically based on dental plaque.1 Rather, they can be caused by a triad of abrasion, erosion, or abfraction.2 NCCLs are associated with the cervical region of a tooth, specifi cally in the region of the cemento enamel junction (CEJ). Treatment is contingent on the extent of gin gival recession, the lesion area, and its relationship to the CEJ.3 When
Volume 34, Number 5, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
650 the lesion presents coronal to the CEJ, restorative intervention may be incorporated into the treatment. When NCCLs are milder, present ing strictly apical to the CEJ, then periodontal or restorative treatment or a combination of the two may be rendered.4,5 Although both periodontal plastic surgery and a restorative ap proach to treating gingival recession have advantages and disadvantag es, historically the more common treatment has been the latter.3 No studies have compared the success of the two treatment modalities. Since periodontal plastic surgery and restorative approaches are both utilized for the treatment of mild NCCLs, this prospective compara tive study was undertaken to deter mine which of the two approaches provides a better outcome for treat ing NCCLs.
Method and materials Institutional review board approval for this prospective randomized clinical trial was received from University Hospitals Case Medi cal Center, Case Western Reserve University, Cleveland, Ohio, USA. Nine patients with 26 sites were recruited into this prospective ran domized clinical trial. Thirteen sites were treated with a subepithelial connective tissue graft (CTG), and 13 sites were treated with a Class V composite resin restoration (CRR). Selection of sites was based on the following inclusion criteria: NCCLs apical to the CEJ, Miller Class I or II gingival recession defects, sites
limited to maxillary nonmolar teeth, and patients ages ≥ 18 years old. Patients were excluded based on the following criteria: NCCLs ex tending coronal to the CEJ, Miller Class III or IV recession defects, mandibular sites, maxillary sites dis tal to the second premolars, previ ously treated noncarious lesions by either periodontal plastic surgery or restorative procedures, patients younger than 18 years old, smokers, pregnant patients, immunocompro mised patients, or any disease or condition that would preclude pa tients from undergoing periodontal surgery. Following selection of sites, pa tients signed a consent form to par ticipate in this study. Each patient had one site randomly assigned to be treated by either a CTG or CRR. The following periodontal clinical parameters were recorded by a sin gle calibrated clinician (ML) at base line and 3 months postoperatively: gingival index (GI), plaque index (PI), probing depths (PDs) at six sites per tooth, percentage bleeding on probing (BOP) at six sites per tooth, gingival recession (GR) on the labial/ buccal surface, clinical attachment levels (CAL), and keratinized gingiva (KG). Using an air-water syringe, air was applied to the buccal surface of the NCCL, and the patient recorded the severity of dentinal hypersensi tivity (DH) on a visual analog scale (VAS) from 0 to 10, where 0 referred to no sensitivity and 10 referred to severe sensitivity. Using digital photography (Canon EOS Digital Rebel T1i SLR Camera, Canon EF 100mm f/2.8 USM Macro Auto Fo cus Lens, and Canon Macro Ring
Lite MR-14EX with E-TTL; Canon USA), photos were taken of the se lected sites. Preoperatively, sites underwent dental prophylaxis and occlusal adjustment as necessary. Sites randomized to receive a CRR were treated by one clinician (ST) using the following protocol: sites were prepared conservative ly, and a retraction cord (Ultrapak, Ultradent) was utilized for ad equate submarginal visualiza tion and hemostasis. A matching shade of composite was chosen, and the tooth was restored, fin ished, and polished (TPH3 Micro Matrix Restorative composite, Dentsply Caulk). Sites randomized to be treated with a CTG were also treated by one clinician (ML) utilizing the technique originally described by Langer and Langer.6 Patients were prescribed the fol lowing medications postoperative ly: amoxicillin 500 mg, 21 tabs to be taken as 1 tab three times daily until finished; ibuprofen 800 mg, 28 tabs to be taken as 1 tab every 8 hours as needed for pain; and a methylprednisolone pack as di rected. Patients were scheduled for follow-up at 2 weeks, 6 weeks, and 3 months. At 3 months post operatively, patients were instruct ed to score the esthetics of the two sites treated from a scale of 0 to 10, where 0 was not esthetic and 10 was most esthetic. Postop erative photographs were taken, and four clinicians not involved in the study, two experienced perio dontists and two prosthodontists, were asked to evaluate the esthet ics of the treated sites using the same scale of 0 to 10. Using an
The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
651 air-water syringe, air was applied to the sites, and the patient recorded the degree of DH on a VAS. All data were analyzed statistically with the Wilcoxon signed rank test with sta tistical significance at P ≤ .05.
Results Of the nine patients with 26 sites that were treated in this study, one patient did not return for his final postoperative appointment, and thus, eight patients with 24 sites were included in the final data col lection: 12 sites that underwent a subepithelial CTG and 12 sites that underwent a Class V CRR. When comparing the change in periodontal clinical parameters, there was a statistically significant improvement in GI, PI, BOP, GR, KG, and CAL (Table 1). There was no statistically significant improve ment in PD at six sites per tooth, yet the data were close to significant (P = .06). The percentage of mean root coverage 3 months after sur gery was 82%, with 75% achieving complete coverage. In the patients’ own evaluations of final esthetics using a scale of 0 to 10, there were statistically sig nificant higher esthetic scores given to sites with the CTG treatment in comparison to the CRR treatment (means: CTG = 7.9 ± 1.7, CRR = 5.5 ± 2.5, P = .03). The two periodon tists and two prosthodontists who scored the esthetics did not find a statistical difference in esthetics be tween the two treatments (means: CTG = 6.3 ± 1.3, CRR = 6.4 ± 1.8, P = .86).
Table 1 Change in study measures within treatments and difference between treatments Measures
CTG (mean ± SD)
CRR (mean ± SD)
Difference* (mean ± SD)
P value†
GI
–0.38 ± 0.27
0.63 ± 0.44
–1.01 ± 0.47
.002
BOP (%)
–0.21 ± 0.22
0.18 ± 0.31
–0.39 ± 0.27
.007
CAL (mm)
–0.60 ± 0.49
0.04 ± 0.41
–0.64 ± 0.62
.005
PD (mm)
–0.25 ± 0.43
0.04 ± 0.41
–0.29 ± 0.54
.06
GR (mm)
–2.04 ± 0.96
0.08 ± 0.51
–2.12 ± 1.09
.003
PI
–0.05 ± 0.62
0.35 ± 0.81
–0.40 ± 0.50
.02
KG
0.92 ± 1.0
–0.33 ± 1.07
1.25 ± 1.14
.008
DH
–1.25 ± 3.74
–1.5 ± 3.09
0.25 ± 2.91
.77
*Treatment differences = change in CTG – change in CRR; negative values favor the CTG treatment for all measures except KG, for which a positive number favors CTG treatment. † Based on Wilcoxon signed rank test. Values in bold are statistically significant at P < .05.
a
b
c
d
Fig 1 (a) Preoperative and (b) 3-month postoperative images of CRR treatment of an NCCL on a maxillary right central incisor. (c) Preoperative and (d) 3-month postoperative images of subepithelial CTG treatment of an NCCL on a maxillary left central incisor.
The mean change in DH be tween baseline and 3 months did not reach a statistically significant difference between the two treat ments (P = .77; see Table 1). In this particular outcome criteria, the authors also sought to analyze the DH for matched sites that attained 100% root coverage, but there was still no statistical difference (means: CTG = –1.89 ± 3.3, CRR = –1.22 ± 2.5, P = .55). Comparing only sites with severe DH (VAS score ≥ 6 at baseline), there was a statistically significant improvement in DH in patients in the CTG treatment from baseline to 3 months postopera
tively (means: initial = 7.83 ± 1.3, final = 4.0 ± 2.5, P = .03). When comparing analogous sites in the CRR treatment, there was no sta tistically significant improvement in DH (means: initial = 7.0 ± 2.0, final = 3.25 ± 3.5, P = .25).
Discussion This study evaluated the periodontal health, esthetics, and dentinal hy persensitivity of NCCLs treated by a subepithelial CTG versus a Class V CRR (Fig 1). Although there have been studies that have taken into
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652 account the ability to predictably perform root coverage procedures on already restored NCCLs,5 this is the first study that was able to iden tify mild NCCLs that could be treat ed by either of the two treatments alone and attempted to determine which treatment is more favorable. There was a significant differ ence in the change of GI, PI, and BOP in the CTG treatment in com parison to the CRR treatment. The change can be attributed to the elimination of the plaque-retentive environment of the NCCLs, whereas there was an impingement of the re storative material on the gingival sul cus in the CRR treatment sites. In the latter, irregular restorative margins, irregular surface of the restoration, or overcontouring of the restoration may have created a more plaqueretentive environment and increased gingival inflammation. There was a statistically signifi cant difference in the mean change of gingival recession measurements between both treatments. The mean root coverage attained in the CTG treatment was 82%. One hundred percent root coverage was attained at 75% of sites (9 of 12). The sub epithelial CTG is the gold standard treatment for root coverage pro cedures according to a systematic review by Chambrone et al.7 The range of mean root coverage in Chambrone’s review was 64.5% to 97.3%. The range for complete root coverage was 8.6% to 96.1%. In a systematic review by Oates et al,8 the mean root coverage was 77.9%, and 37.4% of sites attained 100% root coverage. The American Academy of Periodontology informational pa
per on oral reconstructive and cor rective considerations in periodontal therapy reported that the mean root coverage was 84% for connective tissue graft techniques.9 In addition, Greenwell and Bissada reported a mean root coverage of 82%.10 The mean root coverage of 82% and the complete root coverage of 75% in this study are comparable to the abovementioned reviews. This study indicates that patients believe that the CTG treatment is a more esthetic treatment than the CRR treatment. When esthetics was scored by a panel of two periodon tists and two prosthodontists, there was no statistical difference between the two treatments. It is possible that periodontists and prosthodontists were more critical in judging the es thetic outcome than the laypersons; or in the eyes of a clinician, mild NCCLs may not pose an esthetically significant difference when compar ing these two treatments. The con cept of “minimal clinically important difference (MCID)” as introduced by Jaeschke et al11 has much signifi cance on these findings. Jaeschke et al defined MCID as the “smallest difference in score in the domain of interest which patients perceive as beneficial and which would man date . . . a change in the patient’s management.”11 Therefore, in the present study, although the panel of clinicians did not perceive an es thetic difference between the two treatments, since patients believed that the CTG treatment was more esthetically beneficial, from an es thetic point of view, the CTG treat ment should be the treatment of choice for mild NCCLs.
At the completion of the study, it was decided to utilize the root coverage esthetic score (RES) as introduced by Cairo et al12 to score the esthetics of the NCCLs for the CTG treatment. The RES takes into account not only the root coverage, but also the gingival margin align ment (scalloped or flat), tissue tex ture (scars or keloids), mucogingival junction alignment (continuous with adjacent teeth or not), and tissue color (color integration with adja cent tissue). Since root coverage is the primary goal, it is given the most weight, where complete root coverage has a score of 6, partial root coverage has a score of 3, and no coverage has a score of 0. The rest of the categories have a score of either 0 or 1 (Fig 2). In the pres ent study, the mean RES was 7.6, which is within range of the Cairo et al mean RES of 7.8. Therefore, this study clearly supports the con clusion of Cairo et al that although root coverage is the most important outcome parameter for soft tissue grafting, emphasis should also be placed on the overall esthetics of the teeth being covered. It may be difficult to objec tively compare the esthetics of the two treatments. In fact, one may contend that the composite res toration is not esthetic at all but rather cosmetic. Touyz et al13 took the meanings of the words esthetic and cosmetic and applied them to dentistry: “cosmetic dentistry re fers to a result that does not neces sarily function ideally and does not always emulate the pristine state of natural tissue.” Esthetic dentistry, however, “incorporates acceptable
The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
653 biologics for long-term survival, and mimics the pristine state of the natural tissue.” Therefore, it would seem that a subepithe lial CTG for NCCLs is an esthetic treatment since it mimics the pris tine state of the natural dentition, whereas a Class V composite res toration for NCCLs is a cosmetic treatment since it does not return the gingiva to its physiologic and harmonious state within the con fines of the tooth (Figs 3 and 4). Accordingly, when 100% root cov erage is attained after periodontal plastic surgery procedures, even if there is a failure to meet the es thetic criteria in the RES of Cairo et al, at the very least it may be considered cosmetic. Based on this concept, one may also postulate that the proper term when com paring the two treatments is not a comparison of esthetics nor a com parison of cosmetics, rather simply a comparison of appearance. When discussing DH, it should be pointed out that this is the first study that compares root cover age procedures to restorative pro cedures with DH as an outcome measure. Although there was no statistical difference when com paring DH between the two treat ments, there was a significant difference in DH when comparing more severe DH sites. From a clini cally relevant standpoint, however, both treatments were able to low er DH significantly (mean change: CTG = 3.83, CRR = 3.75). Although systematic reviews in the periodon tal literature state that DH can be decreased with root coverage pro cedures,8 there are very few clinical
Root coverage esthetic score (RES) Esthetic criteria Root coverage
RES system
Score
No coverage = 0 Partial coverage = 3 Complete coverage = 6
6
Gingival margin Flat gingival margin = 0 alignment Scalloped gingival margin = 1 Texture
Scar or keloid formation = 0 No scar or keloid formation = 1
Mucogingival junction alignment
Not aligned with adjacent teeth = 0 Aligned with adjacent teeth = 1
Tissue color match
No tissue color match = 0 Tissue color match = 1
1 0 0 RES = 8
1
Fig 2 Calculation of RES for a maxillary right first premolar.
a
b
a
b
Fig 3 (a) Three-month postoperative image of a maxillary left first premolar treated with CRR. Note the well-blended restoration and the appearance of a longer tooth. (b) Three-month postoperative image of a maxillary right first premolar treated with a subepithelial CTG. Note scar tissue formation and complete root coverage.
Fig 4 (a) Three-month postoperative image of a maxillary right lateral incisor treated with CRR. Note the well-blended restoration yet the appearance of a long tooth with rolled gingival margins. (b) Three-month postoperative image of a maxillary left lateral incisor treated with a subepithelial CTG. Note the well-blended keratinized tissue texture and color, which restores the natural appearance.
studies that have specifically fo cused on root coverage and DH.14 It is noteworthy that long-term studies on CTG have shown stabil ity with minimal relapse,15 whereas Class V CRRs have a tendency to debond and become discolored over time.16 It is suggested for fur ther research to evaluate the impact of these characteristics on a larger scale with a longer follow-up.
Conclusions The results of the present study in dicate that a subepithelial CTG is a superior treatment option com pared with a Class V CRR for mild NCCLs based on periodontal health parameters. From a patient point of view, the subepithelial connective tissue graft is a more esthetic treat ment. Therefore, when esthetically
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654 demanding patients present with a NCCL, appropriate evidence-based guidelines should be provided to enable them to choose the treat ment that suits their esthetic re quirements even when there may not be a discernible difference in the clinicians’ eyes.
Acknowledgments The authors reported no conflicts of interest related to this study.
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11. Jaeschke R, Singer J, Guyatt GH. Mea surement of health status: Ascertaining the minimal clinically important difference. Control Clin Trials 1989;10:407–415. 12. Cairo F, Rotundo R, Miller PD, Pini Prato GP. Root coverage esthetic score: A sys tem to evaluate the esthetic outcome of the treatment of gingival recession through evaluation of clinical cases. J Periodontol 2009;80:705–710. 13. Touyz LZ, Raviv E, Harel-Raviv M. Cos metic or esthetic dentistry? Quintessence Int 1999;30:227–233. 14. Douglas de Oliveira DW, Marques DP, Aguiar-Cantuária IC, Flecha OD, Gon çalves PF. Effect of surgical defect cov erage on cervical dentin hypersensitivity and quality of life. J Periodontol 2013;84: 768–775. 15. Cortellini P, Prato GP. Coronally ad vanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience. Periodontology 2000 2012; 59:158–184. 16. Peumans M, Kanumilli P, De Munck J, Van Landuyt K, Lambrechts K, Van Meerbeek B. Clinical effectiveness of contemporary adhesives: A systematic review of cur rent clinical trials. Dent Mater 2005;21: 864–881.
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