J Clin Periodontol 2009; 36: 434–441 doi: 10.1111/j.1600-051X.2009.01389.

Cervical restoration and the Mauro Pedrine Santamaria, Daniela

da Silva Feitosa, Francisco Humberto
Nociti Jr., Marcio Zaffalon Casati,

amount of soft tissue coverage Antonio Wilson Sallum and Enilson

Antônio Sallum
Department of Prosthodontics and

achieved by coronally advanced Periodontics, Division of Periodontics,

Piracicaba Dental School, University of
Campinas – UNICAMP, São Paulo, SP,

flap: A 2-year follow-up Brazil

randomized-controlled
clinical trial
Santamaria MP, Feitosa DS, Nociti Jr. FH, Casati MZ, Sallum AW, Sallum EA.
Cervical restoration and the amount of soft tissue coverage achieved by coronally
advanced flap. A 2-year follow-up randomized controlled clinical trial. J Clin
Periodontol 2009; 36: 434–441. doi: 10.1111/j.1600-051X.2009.01389.x.

Abstract
Background: The aim of this study was to evaluate the 2-year follow-up success of
the treatment of gingival recession associated with non-carious cervical lesions by a
coronally advanced flap (CAF) alone or in combination with a resin-modified glass
ionomer restoration (CAF1R).
Material and Methods: Sixteen patients with bilateral Miller Class I buccal gingival
recessions, associated with non-carious cervical lesions, were selected. The defects
received either CAF or CAF1R. Bleeding on probing (BOP), probing depth (PD),
relative gingival recession (RGR), clinical attachment level (CAL) and cervical lesion
height (CLH) coverage were measured at the baseline and 6, 12 and 24 months after
the treatment.
Results: Both groups showed statistically significant gains in CAL and soft tissue
coverage. The differences between groups were not statistically significant in BOP,
PD, RGR and CAL, after 2 years. The percentages of CLH covered were
51.57  17.2% for CAF1R and 53.87  12.6% for CAF (p40.05). The estimated
root coverage was 80.37  25.44% for CAF1R and 83.46  20.79% for CAF
Key words: cemento-enamel junction; gingival
(p40.05). recession/surgery; glass ionomer cement;
Conclusion: Within the limits of the present study, it can be concluded that both surgical flap; tooth abrasion
procedures provide acceptable soft tissue coverage after 2 years, with no significant
differences between the two approaches. Accepted for publication 24 January 2008

Conflict of interest and source of

funding statement Owing to the reduction of caries preva- exposure of the root surface (Wennström
lence in several populations, teeth are 1996, Cairo et al. 2008). This is a common
The authors report no conflicts of interest functional for longer periods. This may finding in patients with a high standard of
related to this study.
The study was funded by the Research
expose the teeth to conditions other than oral hygiene, as well as in periodontally
Foundation of the State of São Paulo – caries and, as a consequence, different untreated populations with poor oral
FAPESP (grant # 06/01437-0, Brazil). problems can arise. Gingival recession is hygiene, especially in elderly people
an apical shift of the gingival margin with (Löe et al. 1992, Serino et al. 1994).
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 Root coverage on restored root surface 435

The absence of the gingival tissue Campinas (CEP-UNICAMP 104/2005). were given to each patient. Patients
protecting the root surface may facilitate Informed consent was signed by each were also encouraged to avoid excessive
the occurrence of other problems, such subject after a thorough explanation of consumption of acidic beverages or
as aesthetic complaints, dentin sensitiv- the nature, risks and benefits of the acidic foods. When necessary, selective
ity, root caries and cervical wear (Gold- clinical investigation and associated grinding was performed to remove
stein et al. 2002). Sangnes & Gjermo procedures. occlusal interferences on the teeth
(1976) reported that gingival recession included in the study. Scaling, root
and a wedge-shaped defect in the cervi- planing and crown polishing were per-
Study population
cal area were often seen affecting the formed as necessary.
same tooth. Another report mentions Sixteen patients, nine males and seven
that no signs of the cemento-enamel females, aged 26–58 years (mean age Clinical assessments
junction (CEJ) were observed in about 37.4  8.8 years), were included. The
50% of the examined teeth showing subjects were selected from the group of After this initial therapy, the following
gingival recession, due to cervical abra- patients referred for periodontal treat- parameters were recorded: (1) full-
sion (Zucchelli et al. 2006). Despite this ment to the Graduate Clinic of the mouth visible plaque index (Ainamo &
close association between gingival Piracicaba Dental School, University Bay 1975) full-mouth visible plaque
recession and non-carious cervical of Campinas – UNICAMP. The patients index (FMPI) and presence or absence
lesions, restorative procedures such as were selected from May to December of visible plaque (VPS) at the site
composite restoration are frequently 2005, according to the following elig- included in the study; (2) full-mouth
selected as the single therapy to treat ibility criteria: sulcus bleeding index (FMBI) (Mühle-
this condition (Terry et al. 2003a). How- mann & Son 1971) and presence or
ever, optimal functional and aesthetic (1) Presence of bilateral Class I Miller absence of BOP at the site included in
results may require the combined use of gingival recession associated with the study; (3) PD, assessed as the dis-
periodontal and restorative procedures non-carious cervical lesion 1–2 mm tance from the gingival margin to the
(Terry et al. 2003b). deep in maxillary canines or pre- apical end of the gingival sulcus; (4)
As shown previously, gingival reces- molars. The pair of recessions asso- relative gingival recession (RGR) mea-
sions associated with non-carious cervi- ciated with the cervical wear in each sured as the distance from the gingival
cal lesions can be successfully treated patient must be comparable (same margin to the incisal border of the tooth;
by glass ionomer restoration combined size). (5) relative clinical attachment level
with the coronally advanced flap (CAF), (2) Non-smokers. (CAL) as PD1RGR; (6) non-carious
with or without connective tissue graft (3) Systemically and periodontally cervical lesion height (CLH), as the
(Santamaria et al. 2007, 2008). After the healthy. distance between the coronal and apical
healing period, good aesthetic outcome (4) No contraindication for periodontal margins of the non-carious cervical
and gingival health with no signs of surgery. lesion; (7) height of the non-carious
inflammation, such as redness and (5) Had not taken medications known cervical lesion located on the root sur-
bleeding on probing (BOP), were to interfere with periodontal tissue face (CLH-R): the CEJ was estimated
observed despite the subgingival loca- health and healing. by the method described by Zucchelli et
tion of part of the restoration. These and (6) Probing depth (PD) of o3 mm al. (2006) using digital photographs
other reports (Thanik & Bissada 1999, without BOP. obtained with a camera positioned per-
Lucchesi et al. 2007) showed successful (7) Tooth vitality, absence of restora- pendicular to the buccal surface of the
outcomes when root coverage surgery tion on cervical area and absence of experimental teeth at a magnification
was performed on the restored root sur- severe occlusal interferences in the ratio of 1:1. The distance from the
face. However, there is a lack of infor- area to be treated. estimated CEJ to the incisal border of
mation about the long-term results of (8) No previous periodontal surgery in the tooth and RGR was measured using
this type of therapy. Therefore, the aim the area. an image analysis software. CLH-R was
of the present study is to present the 2- calculated by subtracting the distance
year follow-up results of a split-mouth, The patients were referred for from the estimated CEJ to the incisal
randomized-controlled clinical trial in periodontal treatment based on their border from RGR. This parameter
which gingival recession, associated complaints (dentin sensitivity and/or allowed the calculation of the percen-
with a non-carious cervical lesion, was aesthetic concerns). Considering that a tage of root coverage. The subtraction of
treated by the CAF combined or not non-carious cervical lesion may be the the non-carious CLH on the root from
with resin–glass ionomer restoration. consequence of a multifactorial process, the total CLH provided the amount of
The hypothesis that the sites treated including tooth structure loss caused by cervical lesion located on the crown
with the associated approach (CAF1R) nonbacterial acids (erosion), traumatic (CLH-C); (8) keratinized tissue width
could present more recession over time tooth brushing (abrasion) and occlusal (KTW), measured as the distance from
was addressed. loading (abfraction), all the patients the gingival margin to the mucogingival
were included in a pre-treatment junction; and (9) keratinized tissue
programme in order to eliminate the thickness (KTT).
Material and Methods possible aetiologic factors related to a PD was measured using a manual
Before the beginning of the study, the non-carious cervical lesion and gingival periodontal probe. The RGR, non-CLH
consent form and the protocol of the recession, as follows: oral hygiene and KTW were measured using a pair of
study were approved by the Institutional instructions using a non-traumatic dividers and a digital caliper with 0.01-
Review Board of the State University of brushing technique and a soft toothbrush mm precision. The KTT was measured
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436 Santamaria et al.

using a pierced endodontic spreader, Two oblique vertical incisions were between the groups. The CLH, and the
perpendicular to a mid-point location extended beyond the mucogingival height of the non-carious cervical lesion
between the gingival margin and the junction and a trapezoidal mucoperios- located on the root (CLH-R) and on the
mucogingival junction, and through the teal flap was raised up to the mucogin- crown (CLH-C) surfaces were examined
soft tissue with light pressure until a gival junction. After this point, a by the Wilcoxon test to evaluate differ-
hard surface was felt. The silicone stop split-thickness flap was extended api- ences between groups. The VPS and the
was then placed in tight contact with the cally, releasing the tension and favour- BOP at the site included in the study
external soft tissue surface. After care- ing coronal positioning of the flap. In the were examined by the McNemar test to
fully removing the spreader, penetration CAF group, the root and non-carious evaluate differences within groups and
depth was measured with a digital cali- cervical lesion were planed with a fin- by the w2 test to evaluate differences
per. PD, RGR, CAL, visible plaque at ishing bur (KG Sorensen 9803FF, São between groups. The KTW and the KTT
the site (VPS) included in the study and Paulo, Brazil) and curettes until the were examined by the Wilcoxon test to
BOP were measured at the baseline and tooth surface became smooth. In the evaluate differences within and between
6 months, 1 and 2 years after surgery. CAF1R sites, a sterile rubber dam was groups. A significance level of 0.05 was
The KTW and KTT were obtained at the placed to isolate the operative field and adopted for all statistical comparisons.
baseline and at 2 years post-operatively. complete restoration of the non-carious
The restorations were also analysed cervical lesion was performed with
after 2 years in function. The presence resin-modified glass ionomer cement Power calculation
or absence of retention of the restoration (Vitremer – 3M ESPE, St. Paul, MN, The study power was calculated using
in the cavity, marginal adaptation and USA), following the manufacturer’s the SAS 9.01 software (Release 9.1,
colour match were observed. instructions. The restoration was per- 2003, SAS Institute Inc., Cary, NC,
Before the beginning of the study, the formed in order to re-establish the entire USA), considering the SD of each group
examiner (M. P. S.) measured the PD defect caused by the cervical wear. of the present study. A difference of
and RGR of all the patients, two times, Later, the epithelium on the adjacent 1.0 mm between CAF and CAF1R
within 24 h, with at least a 1-h interval papillae was stripped away and the flap groups was considered as clinically sig-
between the examinations. The exami- was coronally positioned and sutured nificant. The power value was evaluated
ner was judged to be reproducible after (6.0 Polyglactin 910 (Vicryl), Ethicon for RGR and relative CAL in the final
fulfilling the pre-determined success cri- INC, São José dos Campos, Brazil) to period of the evaluation. A minimum
teria. The k index was calculated for completely cover the non-carious cervi- power value of 77% was achieved (for
PD, resulting in 91% reproducibility, cal lesion in the CAF group and the the relative CAL parameter at 2 years).
and the intra-class correlation was cal- restoration in the CAF1R group.
culated for RGR, resulting in 89%
agreement. The examiner was not Post-operative care Results
masked because it was possible to
observe whether the glass ionomer Patients were instructed to take analge- A flow diagram of participants in the
restoration had been applied at the site. sics (500 mg sodium dipyrone every 6 study is provided (Fig. 1). Table 1 shows
hours for 2 days) and were instructed to the patients’ characteristics at baseline.
discontinue toothbrushing around the No adverse event was observed in any
Surgical procedures
surgical sites during the initial 30 days patient during the study.
All the surgical procedures were carried after surgery. During this period, plaque
out by one operator (E. A. S.). The sites control was achieved with a 0.12% chlor-
Cervical lesion
were randomly assigned, by the flipping hexidine solution rinse used twice a day.
of a coin (F. F. S.), to the control group After this period, gentle toothbrushing The mean CLH was 2.54  0.5 mm for
or to the test group. A second coin flip with a soft-bristle toothbrush was allowed. the test group and 2.58  0.42 mm for
was carried out to define the sequence of Sutures were removed after 7 days
treatments to be performed. The control and the patients were enrolled in a
group received the CAF (CAF group) and periodontal maintenance programme
the test group was subjected to a coron- (professional plaque control and oral
ally advanced flap plus a resin-modified hygiene instruction) weekly during the
glass ionomer restoration (CAF1R first month, monthly during the first 6
group). The pair of recessions and non- months and every 4 months until the end
carious cervical lesions of each patient of the study period.
was treated in the same surgical session.
Briefly after local anaesthesia (Lido- Statistical analysis
caine with 1:100,000 Epinephrine), an
intra-sulcular incision was made at the Descriptive statistics were expressed as
buccal aspect of the involved tooth. Two means  standard deviation (SD). The
horizontal incisions were made at right PD, RGR and relative CAL were exam-
angles to the adjacent interdental papil- ined by the Friedman test to evaluate
lae, 1 mm apical to the level of the differences within groups, followed by a Fig. 1. Flowchart for the study patients.
coronal border of the non-carious cervi- post hoc non-parametric test for multi- CAF, coronally advanced flap group;
cal lesion, without interfering with the ple comparisons and by the Wilcoxon CAF1R, coronally advanced flap plus
gingival margin of neighbouring teeth. signed rank test to evaluate differences restoration group.
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 Root coverage on restored root surface 437

Table 1. Patients’ characteristics at the base-

line (N 5 16)
Age 26–58 (mean age 37.4  8.8 years)
Gender Nine males and seven females
Canines: 4 (12.5%)
Teeth 1PM: 26 (81.25%)
2PM: 2 (6.25%)
FMPI 16.5%
FMBI 18.82%
FMPI, full-mouth visible plaque index; FMBI,
full-mouth sulcus bleeding index.

the control group (p40.05). Using the Fig. 5. Coronally advanced flap site after 2
method described by Zucchelli et al. years of the treatment. Note that the coronal
(2006), it was possible to estimate the part of the cervical lesion is supragingival.
Fig. 2. Pre-operative view of the coronally
place where the lost CEJ was located. advanced flap site.
Consequently, it was possible to identify
the total amount of root (CLH-R) and
crown (CLH-C) affected by the non-
carious cervical lesion. CLH-R was
1.7  0.42 for the test group and 1.68 
0.36 for the control group, representing
67.19  11.81% and 65.68  7.52% of
the total CLH, respectively. CLH-C was
0.84  0.32 mm for the test group and
0.9  0.21 mm for the control group.
The differences observed between the
groups were not statistically significant
for these parameters (p40.05).

Gingival recession Fig. 6. Pre-operative view of the coronally

Fig. 3. Coronally advanced flap site after 6 advanced flap plus restoration group site.
All sites presented a reduction of months of the treatment.
1.31  0.37 mm in the RGR for the
test group and of 1.39  0.41 mm for
the control group (p40.05). The cover-
age obtained at 6 months remained
stable over time for both the groups.
These reductions in the RGR represent
51.57  17.2% CLH coverage for the
test group and 53.87  12.6% for the
control group. This difference was not
statistically significant (p40.05). No
site in either group had achieved com-
plete CLH coverage after 2 years of
observation. The maximum CLH cover-
age was 78.18% for the CAF1R group
and 76.66% for the CAF group.
The percentage of root coverage was
calculated at the end of the study period. Fig. 4. Coronally advanced flap site after
The test group showed a mean root 1 year of the treatment. Fig. 7. Coronally advanced flap plus
coverage of 80.37  25.44% and the restoration group site after 6 months of the
control group showed 83.46  20.79%. treatment.
The difference between the groups was PD and CAL
not statistically significant (p40.05).
Table 1 shows the characteristics of The PD did not change significantly in the control group; it was
the cervical lesion in each group and during the baseline to the 2-year fol- 1.31  0.47 mm at the baseline and
the total amount of coverage achieved. low-up. In the test group, this parameter 1.5  0.51 mm at the 2-year evaluation.
Figures 2–9 show the clinical aspect at did not change significantly between The differences between and within
the baseline and the post-operative per- baseline and 2 years after surgery groups were not statistically significant
iods of the control and the test groups. (1.25  0.44 mm for both the periods) (p40.05).
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438 Santamaria et al.

Table 2. Mean values and standard deviation for CLH and CLH-R
Test group Control group p-value

CLH 2.54  0.5 mm 2.58  0.42 mm 0.93

CLH-R 1.7  0.42 mm 1.68  0.36 mm 0.8
(67.19  11.81%) (65.68  7.52%)
CLH-C 0.84  0.32 mm 0.9  0.21 mm 0.67
CLH coverage 51.57  17.2% 53.87  12.6% 0.13
Root coverage 80.37  25.44% 83.46  20.79% 0.8
p-values were calculated by the Wilcoxon test to evaluate differences between the groups.
CLH, non-carious cervical lesion height; CLH-R, non-carious cervical lesion height located on the
root; CLH-C non-carious cervical lesion height located on the crown

Table 3. Clinical results (mean  SD; N 5 16 patients)

Baseline 6 months 1 year 2 years
Fig. 8. Coronally advanced flap plus
restoration group site after 1 year of the PD
treatment. CAF1R 1.25  0.44 1  0.36 1.12  0.5 1.25  0.44
CAF 1.31  0.47 1.37  0.5 1.5  0.51 1.5  0.51
CAL
CAF1R 11.73  1.15 10.14  0.95n 10.30  1.26n 10.42  1.0n
CAF 11.56  0.72 10.21  0.83n 10.37  0.95n 10.36  0.97n
RGR
CAF1R 10.48  1.09 9.14  1.0n 9.17  0.99n 9.17  1.0n
CAF 10.25  0.81 8.84  0.77n 8.87  0.81n 8.86  0.8n
KTT
CAF1R 1.16  0.13 – – 1.07  0.2
CAF 1.12  0.16 – – 1.04  0.33
KTW
CAF1R 3.16  0.85 – – 3.11  0.91
CAF 3.24  0.4 – – 3.25  0.56
n
Statistically significant difference within the groups (po0.05) by the Friedman test.
w
Statistically significant difference between the groups (po0.05) by the Wilcoxon test.
CAF, coronally advanced flap group; CAL, clinical attachment level; CAF1R, coronally advanced
flap plus resin-modified glass ionomer restoration group; KTT, keratinized tissue thickness; KTW,
keratinized tissue width; PD, probing depth; RGR, relative gingival recession; SD, standard
deviation.

Fig. 9. Coronally advanced flap plus Bleeding on probing

restoration group site after 2 years of the
treatment. Note the aesthetic appearance of
FMBI remained low during the entire
the restoration and the health of the gingival study period, being 16.5% at the base-
tissue. line and 19.2% at the 2-year evaluation
(p40.05), demonstrating that the
patients had performed acceptable oral
hygiene. Additionally, low levels of
After 2 years, both the groups showed FMPI were observed: 18.82% at the
statistically significant changes from baseline and 21.3% at the 2-year evalua-
baseline for CAL: 1.31  0.6 mm for tion. No BOP was observed at any site Fig. 10. Coronally advanced flap plus
the test group (p 5 0.0001) and included in the study in any evaluated restoration group site after 2 years of the
1.2  0.72 mm for the control group period. treatment presenting alteration of the
restoration colour.
(p 5 0.0001). The difference between Restorations
the two groups was not statistically
significant (p40.05) (Table 2). After 2 years in function, the restora-
tions were analysed. All the restorations Discussion
(16 out of 16) were retained at the sites The CAF has shown predictable results
and no restoration was lost. Seven of the in terms of root coverage for intact root
Keratinized tissue
16 restorations (43.75%) presented a Miller Class I gingival recessions (Allen
No significant changes regarding the colour change and their colours did not & Miller 1989, Wennström & Zucchelli
thickness (KTT) and the width (KTW) match the tooth colour. When the colour 1996, Pini-Prato et al. 2000, Cairo et al.
of the keratinized tissue were observed. of the restoration changed, it became 2008). However, the long-term success
Table 3 shows the means and the SDs of darker than the colour of the tooth of the CAF to treat gingival recession,
PD, CAL, RGR, KTT and KTW of the (Fig. 10). Only one out of the 16 pre- associated with a non-carious cervical
test and control groups. sented a marginal discrepancy. lesion, combined with a cervical restora-
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 Root coverage on restored root surface 439

tion or not, has not been addressed in the other studies for this procedure (Allen dam to isolate the operative field might
literature. Thus, the goal of this split- & Miller 1989, Harris & Harris 1994, have maintained the cervical lesion cav-
mouth, randomized-controlled clinical Wennström & Zucchelli 1996, Pini-Pra- ity dry and decontaminated during the
trial was to compare the 2-year follow- to et al. 2000). However, caution should manufacture of the restoration. Addition-
up of gingival recession, associated with be exercised due to the subjective com- ally, all possible aetiological factors
a non-carious cervical lesion, treated by ponent of the method used to estimate related to the occurrence of the non-
CAF plus glass ionomer restoration (test the CEJ in the present study, which carious cervical lesion (e.g. occlusion,
– CAF1R group) and the CAF alone differs from the direct measurement acids and traumatic brushing) were con-
(control – CAF group). obtained in studies with intact roots. trolled, which could have influenced this
The change observed in the RGR This method does not allow precise positive finding (Heymann et al. 1991).
after 2 years was 1.31  0.37 and determination of complete root cover- Another observation is the colour
1.39  0.41 mm for CAF1R and CAF, age achieved by each procedure. alteration of the restorative material
respectively (p40.05). This change in Another consideration is that the present used. In the present study, 7 of the 16
the position of the gingival margin to a study included small Miller Class I (43.75%) of the restorations’ colour did
more coronal level provided a compar- gingival recessions. In spite of the small not match the teeth’s colour after 2 years.
able percentage of CLH coverage size of the recessions, they were con- This finding is also in accordance with
(51.57  17.2% in the CAF1R group sidered sufficiently important by the the literature, which shows low colour
and 53.87  12.6% in the CAF group, patients. Therefore, this associated stability for the resin–glass ionomer over
p40.05) and a gain of CAL lesion is a common clinical finding time (Gladys et al. 1999). There are
(1.2  0.72 mm in the CAF group and that requires further investigation to several factors that may influence resin–
1.31  0.6 mm in the CAF1R group, establish a treatment protocol that could glass ionomer colour, but alterations in
p40.05) after the two treatment deal with the dentin sensitivity and the surface texture are particularly impor-
approaches. Therefore, it could be aesthetic complaints of the patients. tant. Gladys et al. (1999) observed a
assumed that the presence of the restora- The first clinical trial aimed to eval- higher roughness surface of the resin–
tion on the cervical area may not prevent uate the coverage achieved on restored glass ionomer restoration using a scan-
soft tissue coverage by theCAF. It is roots was performed by Thanik & Bis- ning electron microscope, compared with
important to note that the CLH coverage sada (1999). They concluded that simi- other materials after 18 months of use.
reported in the present study should not lar coverage could be obtained However, the increased roughness sur-
be directly compared with other studies regardless of the presence of the restora- face may not have any negative impact
that included gingival recession on tion. Later reports (Lucchesi et al. 2007, on the gingival health. In the present
intact roots. This comparison is not Santamaria et al. 2007, 2008) showed study, no plaque accumulation and no
possible because the non-carious cervi- similar results. However, all these pre- BOP were observed at any site of the
cal lesion simultaneously affects parts of vious studies were short-term reports. test group. Figure 10 shows one tooth
the root and the crown of the tooth and, Long-term studies are strongly recom- allocated to the test group that presented
with its progression, the CEJ generally mended to show the stability of soft colour alteration of the restoration.
disappears (Zucchelli et al. 2006). This tissue coverage over time on restored Although some restorations presented
could explain why no site, neither in the roots achieved after periodontal surgery. colour alteration, only one patient com-
CAF group nor in the CAF1R group, The findings of the present 2-year fol- plained about it. For this patient, a thin
achieved complete CLH coverage and low-up study corroborate previous find- external layer of the supragengival por-
only the part of the non-carious cervical ings (Santamaria et al. 2008) suggesting tion of the restoration was worn out using
lesion located on the root could be that gingival margin stability may be a round diamond bur and a composite
predictably covered by soft tissue after obtained after the CAF is performed on resin layer was applied to correct the
a coronally positioned flap. cervical lesions restored with resin– colour alteration. The remaining patients
In order to explore the hypothesis that glass ionomer cement. considered that good aesthetics was
the uncovered part of the non-carious One important aspect to be evaluated achieved after the procedures. However,
cervical lesion was mainly composed by when using the combined approach caution must be exercised because the
the crown portion of the lesion, an (periodontal surgery plus restoration) to patients were simply asked about it and
estimation of the position of the CEJ treat gingival recession associated with no visual analogue scale or another meth-
by the method described by Zucchelli non-carious cervical lesion is the gingi- od to measure the patients’ aesthetic
et al. (2006) was performed and it was val margin stability over time. The other satisfaction was applied.
possible to estimate the part of the CLH aspect is the restoration. In the present The presence of restoration margins
located on the root (CLH-R). The CLH- study, some interesting observations close to the gingival margin or within
R was 1.7  0.42 mm (67.19% of the were made regarding the restoration. the crevicular space has been suggested
CLH) for the CAF1R group and After the 2 years of observation, all the to cause gingival inflammation (Larato
1.68  0.36 (65.68% of the CLH) for restorations were presented at the treated 1972). The results of the present study
the CAF group. Based on these values, sites. This finding is in accordance with are not in agreement with this statement.
the mean root coverage (CLH-R cover- the literature, which shows a low rate of As the amount of soft tissue coverage
age) was calculated and reached loss of resin–glass ionomer cement when achieved in the CAF1R group was
80.37  25.44% for the CAF1R group applied to Class V cavities after 2 years 51.57%, the restorations present in this
and 83.46  20.79% for the CAF group (Abdalla & Alhadainy 1997) and after 5 group remained approximately 50% cov-
(p40.05). The mean values of root years (Loguercio et al. 2003). There are ered by the soft tissue and, as a conse-
coverage observed in the present study several factors that may have influenced quence, the apical margin of the
are comparable to those reported in this result. The utilization of a rubber restoration located subgingivally. How-
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440 Santamaria et al.

ever, no POB or signs of gingival inflam- Allen, E. P. & Miller, P. D. Jr. (1989) Coronal Coronally advanced flap procedure for root
mation were observed during the study positioning of existing gingiva: short term coverage. Flap with tension versus flap with-
period. Dragoo’s (1996, 1997) and Alkan results in the treatment of shallow marginal out tension: a randomized controlled clinical
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the rate of success and the possible Gladys, S., Van Meerbeek, B., Lambrechts, P. with non-carious cervical lesion. A rando-
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tistical analysis included a power value age of previously carious roots is as predict- Terry, D. A., McGuire, M. K., McLaren, E.,
of 77% to detect a clinical significant able a procedure as coverage of intact roots. Fulton, R. & Swift, E. J. Jr. (2003a) Perioes-
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Harris, R. J. & Harris, A. W. (1994) The of carious and noncarious cervical lesions:
CAF1R in RGR and CAL. Therefore,
coronally positioned pedicle graft with inlaid part I. Journal of Esthetic and Restorative
further studies with larger sample sizes margins: a predictable method of obtaining Dentistry 15, 217–232.
are strongly recommended to confirm root coverage of shallow defects. Interna- Terry, D. A., McGuire, M. K., McLaren, E.,
these results. Other studies testing other tional Journal Periodontics and Restorative Fulton, R. & Swift, E. J. Jr. (2003b) Perioes-
different restorative materials and surgi- Dentistry 14, 229–241. thetic approach to the diagnosis and treatment
cal techniques should be performed to Heymann, H. O., Sturdevant, J. R., Bayne, S., of carious and noncarious cervical lesions.
achieve the best combination to treat Wilder, A. D., Sluder, T. B. & Brunson, W. Part II. Journal of Esthetic and Restorative
this particular combined lesion. The D. (1991) Examining tooth flexure effects on Dentistry 15, 284–296.
results of the present study suggest that cervical restorations: a two-year clinical Thanik, S. D. & Bissada, N. F. (1999) Clinical
study. Journal of American Dental Associa- study of connective tissue grafts for root
the combination of CAF for root cover-
tion 122, 41–47. coverage on teeth with cervical lesions with
age and cervical lesion restoration using Larato, D. C. (1972) Influence of a composite and without restoration. Abstract IADR. Jou-
a glass ionomer can provide stable resin restoration on the gingival. Prosthetic nal of Dental Research 78, 119.
results after 2 years. Dentistry 28, 402–404. Wennström, J. L. (1996) Mucogingival therapy.
Löe, H., Anerud, A. & Boysen, H. (1992) The Annals of Periodontology 1, 671–701.
Acknowledgements natural history of periodontal disease in man: Wennström, J. L. & Zucchelli, G. (1996)
prevalence, severity, extent of gingival reces- Increased gingival dimensions. A significant
The authors thank the Foundation for sion. Journal of Clinical Periodontology 63, factor for successful outcome of root coverage
the Development of Personnel in Higher 489–495. procedure? A 2-year prospective clinical study.
Education – CAPES for supporting Loguercio, A. D., Reis, A., Barbosa, A. N. & Journal of Periodontology 23, 770–777.
Dr. Mauro P. Santamaria. Roulet, J. F. (2003) Five-year double-blind Zucchelli, G., Testori, T. & De Sanctis, M.
randomized clinical evaluation of a resin- (2006) Clinical and anatomical factors limit-
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Journal compilation r 2009 John Wiley & Sons A/S
 Root coverage on restored root surface 441

Clinical Relevance gery is combined with glass ionomer Practical implications: The findings
Scientific rationale for the study: restoration. of the present study suggest that the
Gingival recession is frequently Principal findings: The present study combined approach may be consid-
associated with a non-carious cervi- shows that the combination of CAF ered as a treatment option for the
cal lesion. Recent literature has for root coverage and cervical lesion type of lesion included in the study.
reported short-term successful treat- restoration using a glass ionomer can
ment results when periodontal sur- provide stable results after 2 years.

r 2009 John Wiley & Sons A/S

Journal compilation r 2009 John Wiley & Sons A/S