At my Manhattan practice, I came across a recent issue of Journal of Esthetic and Restorative Dentistry, a well-known periodontics journal, discussed the topic of “Noncarious Cervical Lesions: Graft or Restore?” Dr. Pat Allen, a former professor of periodontics and now practitioner, answered the following question: How does one decide the best treatment – restorative versus periodontal – for a noncarious cervical lesion?
As a preface, a noncarious cervical lesion (NCCL), is defined as a loss of hard dental tissue near the cementoenamel junction. This means the place where the crown of the tooth covered in enamel, meets the root of a tooth covered by cementum. Noncarious means that it is not decayed, but the loss of tissue produces a curved or wedge-shaped look. Periodontics professionals have seen these types of problems increasing in prevalence due to a number of lifestyle changes among all ages of patients. These types of lesions can occur at any time and will almost assuredly worsen throughout a patient’s lifetime without treatment. Early diagnosis from a periodontics professional is important to initiate treatment and avoid future, more invasive procedures.
Answer: Unfortunately, treatment of noncarious cervical lesions tends to be dictated by the training of the involved clinician. In other words, general dentists tend to think “restoration” first, and periodontics professionals tend to think “graft for root coverage” first. However, each case should be evaluated methodically using the guidelines below that I use at my Manhattan practice all the time.
Grafting, which means pulling tissue from elsewhere and attaching it to the existing tissue, is better when: There is no attached gingival, no enamel defect is present, there is Class I or II recession, that is, there is no loss of interdental bone or soft tissue, papilla length and fullness are adequate, and/or esthetics are important.
Restoration is better when: There is adequate attached gingival, the defect is mainly in enamel, the lesion is deeper than 2mm horizontally, there is class III recession, that is, there is some loss of inter dental bone height or soft tissue fullness, making complete root coverage not possible, and/or esthetics are not of primary importance.
It may be necessary to both graft and restore when: There is no attached gingival, there is a defect in the enamel, recession is significant (> 2mm), papilla length and fullness are inadequate, and/or esthetics is important.
Periodontics professionals and dentists alike can make these decisions only upon inspection of the patient. Each of these are subject to a slight amount of judgment, especially when judging the importance of certain esthetics. These often depend upon the experience and training of the clinician.
Soft tissues grafting has improved dramatically over the past 20 years. Complete root coverage now is a predictable outcome for Class I and II recessions, even in the presence of root surface defects. Using microscopic surgical techniques these procedures can now be performed with little to no discomfort, fast healing, and exceptional results. Occlusal analysis should also be performed when these lesions are present.
fig. Class I & II no interproximal bone loss can be wide or narrow. Class I recession above mucogingival junction, Class II below MGJ. Class III & IV interprox, bone loss, full root coverage cannot be expected.
Non-carious cervical lesions can very adversely affect the dental longevity and esthetics of a smile. Patients in Manhattan can be assured that when they choose my practice for periodontics work with cases like this and many others, they will be receiving only the highest quality of dental work from a professional with years of experience and skill. Micro-surgical techniques and new technologies have revolutionized and advanced these kinds of procedures and many others.
Call (212) 702-9088 or come in for a consultation, and we can discuss what we can do for you.
