21

A C o n n e c tiv e T is s u e G r a ft as a B io lo g ic
A lte r n a tiv e t o C lass V R e s to ra tio n s in
M ille r C lass I a n d II R e ce ssio n D e fe c ts :
C a se S e rie s

W. Peter N ordland, DMD, MS’ Root exposure can lead to den­

Laura M. de Souza, DDS2 tinal hypersensitivity and caries.
Edward J. Swift, Jr, DMD, MS3 Although Class V restorations treat
these problems as a quick and inex­
pensive dental procedure, they have
significant limitations.
Although cervical lesions are commonly treated using restorative materials, Composite and glass ionomer
the esthetics and durability o f the restoration can be problematic. Despite restorations are often chosen to
improvements in bonding to dentin, the performance o f resin-based cervical
treat carious and noncarious cervi­
restorations suffers from a variety o f clinical problems. Biologic options using
cal lesions. Unfortunately, clinical
connective tissue grafts to replace the lost soft tissues have proven longevity
and esthetic benefits. A collection o f case reports is presented to demonstrate a observations suggest that bonding
surgical alternative to correct carious and noncarious cervical lesions. Clinicians to dentin is less predictable than
should consider the biologic option o f replacing the missing gingival tissue bonding to enamel.1 Weak adhe­
prior to placement o f restorative materials on exposed root surfaces. Int J sion can allow bacteria to under­
Periodontics Restorative Dent 2016;36:21-27. doi: 10.11607/prd.2366
mine the restoration, resulting in
microleakage.2-4 Degradation of the
resin-enamel bond is minimal in vi­
tro and in vivo, as evidenced by the
long-term retention of pit and fis­
sure sealants.5'6 Bonding to enamel
is enhanced by the fact that its com­
position is nearly 100% inorganic.
In contrast, dentin contains much
organic material, is traversed by
fluid-filled tubules, and is therefore
a less predictable and less reliable
substrate for bonding.7
Despite the difficulties in bond­
ing to dentin, continuing advances
Assistant Professor of Periodontics, Loma Linda University, Loma Linda, California, USA; in adhesive technology have result­
Director of the Nordland Oral Microsurgical Institute, La Jolla, California, USA; Director of ed in development of resin-based
Microsurgery, Newport Coast Oral Facial Institute, Newport Beach, California, USA.
agents that provide excellent bonds
Associate of the Nordland Oral Microsurgical Institute, La Jolla, California, USA.
3Professor and Chair, Department of Operative Dentistry, School of Dentistry, to dentin.8'9 The absolute bond
University of North Carolina, Chapel Hill, North Carolina, USA. strength values depend not only on
the type of adhesive being tested,
Correspondence to: Dr Peter Nordland, 850 Prospect Street, Suite 7,
but also on the test method being
La Jolla, CA 92037, USA. Email: [email protected]
used.940 Regardless, numerous in
©2016 by Quintessence Publishing Co Inc. vitro studies have reported that the

Volume 36, Number 1,2016

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initial bond of resin to dentin de ­ quality of subgingival plaque, in­ due to multiple failing Class 5 resto­
grades substantially over time.11-15 creasing total bacterial counts with rations and Miller Class I recession
According to Liu et al,16 "bond deg­ a decrease of gram-positive aerobic defects. The patient was also con­
radation occurs via hydrolysis of sub- bacteria and a significant increase of cerned about the black lines around
optimally polymerized hydrophilic gram-negative anaerobic bacteria. his existing restorations, pitting of
resin components and degradation The addition of a connective the surfaces, and gingival inflamma­
of water-rich, resin-sparse collagen tissue graft to cover root surfaces tion (Fig 1a). A treatment plan was
matrices by matrix metalloproteinas- could raise concern for creation of a established to remove the cervical
es (MMPs) and cysteine cathepsins." periodontal pocket. Minimal prob­ restorations and provide a connec­
The bond degradation observed in ing depth is desirable following root tive tissue graft procedure for teeth
vitro is manifested in loss of reten­ coverage procedures. In 1980, Cole 11 and 21.
tion and degradation of margins in et al showed for the first time that In all of the following cases, the
clinical trials. A recent meta-analysis new attachment in humans was pos­ composite restorations and/or cari­
of clinical trials of cervical restora­ sible.23 Using this same strategy for ous lesions were removed using a
tions revealed retention loss rates new attachment with gingival graft­ surgical dissecting microscope,
ranging from 0 to 50% and marginal ing, human histology has shown rotary, and hand instruments. The
discoloration rates of 0 to 74%.17 connective tissue grafting surgery microscope enhanced visibility to
Clinical performance was best for can achieve new attachment to a ensure that the entire composite
the three-step etch-and-rinse and previously exposed root surface.24’25 was removed. After thorough de­
two-step self-etch systems, as in­ The use of a connective tissue graft bridement and smoothing of all root
dicated by recently reported long­ with a bilaminar technique is well es­ surfaces, tetracycline paste was ap­
term clinical trials.18-20 Even with the tablished.26 plied for 2 minutes. Tetracycline was
most effective adhesives, bonding The Miller classification of re­ used for removal of the smear layer
of resin-based restorations in the cession provides guidelines for and exposure of the dentinal colla­
cervical area can be compromised predictability of root coverage.27 gen fibers.
by the common presence o f scle­ Modern gingival augmentation The Nordland N-6900 microsur-
rotic dentin, which is less receptive techniques can offer predictabil­ gical blade was used to make a split­
to bonding than normal dentin.21 ity in root coverage, regeneration thickness sulcular incision around all
Unfortunately, sclerotic dentin is of attachment, and cosmetics.28-30 facial surfaces, including undermin­
commonly present with chronically It has been shown that periodon­ ing the interdental papilla to avoid
exposed root surfaces. tal root coverage procedures are releasing incisions (Fig 1b). The
In addition to the inherent prob­ highly predictable for Class I and II N-6900 blade was customized using
lems of retention and leakage, poor­ recessions even when root surface orthodontic bending pliers to cre­
ly adapted or contoured cervical defects are present and success ate the precise contours needed to
restorations may also compromise rates for complete root coverage mimic the anatomy of the area (Fig
periodontal health. The restorative range from 92% to 99% and are 1c). The split-thickness dissection
materials themselves can affect the stable o ve rtim e.31'32 is extended past the mucogingival
bacterial flora. For example, Paolan- junction to allow for m obility of the
tonio et al22 reviewed the clinical and undermined facial flap (Fig 1d).
microbiological effects of different Case re p o rts Palatal connective tissue was
restorative materials on periodontal harvested with precise dim en­
tissues adjacent to Class 5 restora­ Case 7 sions to be long enough to extend
tions. They concluded that com­ to the line angles of the adjacent
posite resin restorations can have A 50-year-old nonsmoking man was teeth. The graft was placed inside
negative effects on the quantity and referred to the periodontal practice a tunnel-type recipient bed by

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Fig 1a Failing Class V composite restorations o f teeth 11 and 21 with microleakage.

Fig 1 b Intrasulcular incision performed with the N-6900 microscalpel.
Fig 1c Customization o f the N-6900 blade wth orthodontic pliers.
Fig 1d Split-thickness dissection extending past the mucogingival junction.
Fig 1e Connective tissue graft manipulated into the tunnel.
Fig 1f Gore-Tex sutures anchor graft into ideal location.
Fig 1g Surgical healing after 2 months.

manipulating it with a periodontal Case 2 previous recession defects and the

probe and curet (Fig 1e). A con­ restorative dentist wished to place
tinuous 5-0 Gore-Tex suture was A 36-year-old nonsmoking woman the restorative margins on enam­
used to provide positioning of the presented to the periodontal prac­ el for a normal tooth length and
external flap over the graft with no tice for consideration for gingival to maximize the restorative bond
graft exposure, which could other­ augmentation. She had visited her strength to enamel. This would re­
wise jeopardize cell survival (Fig 1f). restorative dentist, who recom­ quire removal of the composite ma­
The Gore-Tex suture allows custom mended placement of maxillary terial and gingival augmentation to
tensioning of the flap for ideal po­ anterior veneers. A diagnostic wax- the cementoenamel junction (CEJ).
sitioning. The patient was followed up indicated that re-establishing This patient presented with Miller
for 2 months to monitor the surgical normal gingival contours would be Class I recession defects ranging
healing (Fig 1g). ideal as the restorations covered from 2 mm to 3.5 mm (Fig 2a).

Volume 36, Number 1, 2016

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Fig 2a Preoperative view showing

recession defects covered with Class V
composite restorations.

Fig 2b Final healing following restoration

removal and connective tissue graft
surgery.

Fig 3a Extensive recession and a Class V

restoration.

Fig 3b Healing 6 weeks after connective

tissue graft surgery.

The composite was removed tice with a history of multiple Class 5 Case 4
using a surgical microscope and restorations for tooth 23, which had
rotary instruments. The root sur­ a Miller Class II recession defect. A 55-year-old nonsmoking man was
faces were treated with tetracycline Teeth 22 and 24 had Miller Class I referred to the periodontal practice
hydrochloride. A microsurgical tun­ recession defects (Fig 3a). The refer­ for treatment of tooth 43, which had
nel was created using an N-6900 ring dentist and patient were both a Miller Class II recession defect.
microsurgical blade. Bilateral con­ concerned with the progressive re­ This tooth had a failing composite
nective tissue grafts were placed cession associated with the restor­ restoration, 7 mm of obvious gin­
into the tunnel without graft expo­ ative retreatment. gival recession, and an additional
sure, creating a bilaminar vascular The restoration was completely 4 mm of gingival cleft, creating a
supply. A trap door incision was removed with hand and rotary in­ total of 11 mm recession (Fig 4a).
used to minimize postoperative struments and gingival augmenta­ The composite was removed and
discomfort and allow for a closed tion was accomplished for teeth 22 a connective tissue graft placed as
palatal wound. Full root coverage and 23 using a connective tissue described previously to provide root
was achieved through the use of graft harvested from the maxillary coverage with a biologic restoration
connective tissue grafts. The pa­ left palate, which was then placed using autogenous connective tissue
tient was followed postoperatively into a tunnel created with N-6900 (Fig 4b).
for 2 months before returning to microsurgical blades without a re­
the restorative office to complete leasing incision. The graft was sta­
veneer restorations (Fig 2b). bilized with 6-0 Gore-Tex sutures, Case 5
and the healing was monitored for
6 weeks. Even though tooth 24 was A 50-year-old nonsmoking woman
Case 3 not part of the treatment plan, it wanted veneer restorations but had
benefited from the procedure by its experienced significant root decay
A 45-year-old nonsmoking woman close proximity to the targeted area along with a Miller Class II reces­
presented to the periodontal prac­ (Fig 3b). sion on tooth 13. The canine had a

The International Journal of Periodontics & Restorative Dentistry

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Fig 4a Tooth 43 with 17 mm o f recession

and a failing Class V composite restoration.

Fig 4b Root coverage was achieved

through removal o f the restoration and
connective tissue graft surgery.

Fig 5a Recession defects and severe

tooth decay on tooth 73.

Fig 5b Postoperative view 6 years after

caries lesion removal and connective tissue
surgery.

guarded prognosis both functional­ creates an unesthetic long clinical Allen, restorations of cervical lesions
ly and esthetically due to root caries. crown and a questionable long­ should be avoided to circumvent
Teeth 12 and 14 had also experi­ term result. the dilemma of restoring the patho­
enced recession to a lesser degree Ideally, grafted gingival tissue logic dentin.34 Periodontal root cov­
(Miller Class I) (Fig 5a). should establish a new attachment erage procedures are the preferred
The caries lesion was removed, back to the previously exposed root method of treatment because of
all roots were mechanically and surface with a natural tissue appear­ the high predictability for complete
chemically treated as previously ance and should do so with predict­ root coverage.34 In a study evaluat­
described, and a connective tissue ability. Minimal probing depth and ing the level of root coverage with
graft was placed microsurgically us­ long-term success should be goals. connective tissue grafts in humans,
ing a tunneling procedure. The new A biologic rationale for new attach­ Harris found that all grafts were suc­
gingival margin was established at ment has been well established with cessful in producing root coverage,
the CEJ to provide an esthetic foun­ demineralization of the root sur­ with a mean root coverage of 97.7%
dation for the planned restorations face,23 and this rationale has shown in Class I or II defects.35 The results
with gingival tissue symmetry across clinical success with human histolo­ of soft tissue grafting are stable and
anterior maxilla. The patient was fol­ gy following successful gingival root have been shown to last for at least
lowed for 6 years with minimal pock­ coverage procedures.24-25 Tetracy­ 10 years.36
et probing depth (Fig 5b). cline preparation has been demon­ Development and refining of
strated to be effective for removal surgical root coverage techniques
of the smear layer, thereby exposing have enhanced the predictability
Discussion dentinal tubules and the dense net­ and esthetics. Soft tissue grafting
work of collagen fibers that make up can be a minimally invasive proce­
While gingival grafting over root the dentin structure.33 dure and, unlike restorative mate­
surfaces is predictable, bonding to Successful root coverage rials, replace the lost anatomical
root surfaces is not. Even under the grafting has been well document­ structure (gingiva) with autogenous
best circumstances, root bonding ed.27-31-32 According to Winter and tissue. Therefore, a soft tissue graft

Volume 36, Number 1,2016

26

can create ideal esthetics by bring­ Some investigators have gone 2. Abdalla Al, Feilzer AJ. Four-year water
ing the gingiva back to the CEJ. so far as to suggest that a perio­ degradation of a total-etch and two self­
etching adhesives bonded to dentin.
Gingiva will insulate the root from dontist should be consulted before J Dent 2008;36:611-617.
thermal changes and can create placement of restorative materials 3. van Dijken JW, Pallesen U. Long-term
dentin retention of etch-and-rinse and
new attachment to a previously dis­ on the roots to assess the potential
self-etch adhesives and a resin-modified
eased root surface with a stable and for future use of gingival grafts for glass ionomer cement in non-carious
shallow probing depth at the end of root coverage, as placement of any cervical lesions. Dent Mater 2008;24:
915-922.
the healing period .24-25 bonded restoration prior to grafting 4. Brackett WW, Haisch LD, Pearce MG,
Microsurgical blades should might diminish the success rate of Brackett MG. Microleakage of Class
V resin composite restorations placed
allow for minimal incision access such procedures.42
with self-etching adhesives. J Prosthet
and a customized approach, creat­ Dent 2004;91:42-45.
ing insignificant trauma. A tunnel 5. Loguercio AD, Moura SK, Pellizarao A,
et al. Durability of enamel bonding us­
approach avoids scarring. Trauma C onclusions ing two-step self-etch adhesives on
associated with harvesting autog­ ground and unground enamel. Oper
Dent 2008;33:79-88.
enous connective tissue from the The need for and usefulness of root
6. Simonsen RJ. Pit and fissure sealant: Re­
palate can be minimized by keeping surface restorations is limited be­ view of the literature. Pediatr Dent 2002;
all the palatal epithelium in situ and cause current alternatives are avail­ 24:393-414.
7. Swift EJ Jr, Perdigao J, Heymann HO.
using a palatal stent to protect the able not only to restore the lost Bonding to enamel and dentin: A brief
area. gingiva but also to protect the root history and state of the art. Quintes­
sence Int 1995;26:95-110.
Additionally, coverage of pre­ from sensitivity and caries while re­
8. Sarr M, Kane AW, Vreven J, et al. Mi-
viously carious root surfaces with storing a natural esthetic result. crotensile bond strength and interfacial
connective tissue grafts is very pre­ Root coverage with connective characterization o f 11 contemporary ad­
hesives bonded to bur-cut dentin. Oper
dictable and similar to that of intact tissue grafts for carious and noncari­ Dent 2010;35:94-104.
roots, providing esthetic, biologi­ ous lesions has been proven to be 9. Van Meerbeek B, Peumans M, Poitevin
A, et al. Relationship between bond-
cally acceptable, and maintainable predictable. The benefits of replac­
strength tests and clinical outcomes.
results.37 After root surface caries ing the missing tissue with gingiva Dent Mater 2010;26:e100-e121.
are removed, the exposed root should be considered among the 10. Scherrer SS, Cesar PF, Swain MV. Direct
comparison of the bond strength results
presents a similar clinical challenge treatment options available when of the different test methods: A criti­
to noncarious root surfaces for root recession exists. cal literature review. Dent Mater 2010;
26:e78-e93.
coverage grafting, and the treat­
11. Armstrong SR, Vargas MA, Fang Q, Laf-
ment is equally predictable .37 foon JE. Microtensile bond strength of a
Interdisciplinary care is some­ A c k n o w le d g m e n ts total-etch 3-step, total-etch 2-step, self­
etch 2-step, and a self-etch 1-step den­
times necessary. It is theorized that tin bonding system through 15-month
tooth flexure with occlusal forces The authors wish to thank Dr Paul Rosen water storage. J Adhes Dent 2003;5:
and Anthony De Cino for their help in the 47-56.
can cause loss of enamel at the CEJ,
12. Frankenberger R, Strobel WO, Lohbauer
creating what has been termed an preparation of this manuscript. The authors
U, Kramer N, Petschelt A. The effect
reported no conflicts of interest related to of six years of water storage on resin
abfract/on.38-39-40 If cervical enamel is
this study. composite bonding to human dentin.
lost, the CEJ can be identified and J Biomed Mater Res B Appl Biomater
replicated according to the location 2004;69:25-32.
13. De Munck J, Shirai K, Yoshida Y, et al. Ef­
of the CEJ of contralateral homolo­ R efe ren c e s
fect of water storage on the bonding ef­
gous or adjacent teeth .41 A com­ fectiveness of 6 adhesives to Class I cavity
posite restoration may be used to 1. Carvalho RM, Manso AP, Geraldeli S, dentin. Oper Dent 2006;31:456-465.
Tay FR, Pashley DH. Durability of bonds 14. Osorio R, Pisani-Proenca J, Erhardt MC,
reconstruct the CEJ, while the con­ et al. Resistance of ten contemporary
and clinical success of adhesive restora­
nective tissue graft will reconstruct tions. Dent Mater 2012;28:72-86. adhesives to resin-dentine bond degra­
dation. J Dent 2008;36:163-169.
the missing soft tissue.

The International Journal of Periodontics & Restorative Dentistry

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