Providing optimal treatment for patients with cervical lesions requires creating a vision of the desired outcome before treatment and establishment of a facially generated treatment plan by the interdisciplinary team.
The correct tooth form for the patient should be based on esthetics, phonetics, function, and establishing the width-to-length ratio of the teeth, which is critical to creating a beautiful smile. The three interrelated components required for optimal tooth proportion are incisal edge position, tooth length and gingival level.
From a perio-restorative perspective, six questions must be answered:
- What are the patient's concerns?
- What are the dimensions of the gingiva?
- What is the depth of cervical lesions?
- What is the depth of the recession?
- Can the root be completely covered?
- Does the lesion involve the root only?
These are the points you should consider for each question:
- What are the patient's concerns? The primary patient concern generally relates to the esthetic compromise created by a long tooth in their smile. When gingival recession occurs exposing the root of the tooth, the tooth width-to-length ratio can significantly change. Many consider long teeth caused by gingival recession a sign of aging, and want treatment to create a more youthful appearance. In addition, the patient may be experiencing tooth sensitivity. There may be sensitivity if the root exposure occurred rapidly. Decay may be present as the root is more susceptible to decay, and influenced by decreased salivary flow due to age or use of medications. Irregular tooth surfaces and ledges may cause increased plaque retention and food entrapment. The suggested method of treatment to solve a long tooth because of gingival recession that negatively impacts facial esthetics, is coronally advancing the soft tissue with or without a graft, depending on the adequacy of soft tissue thickness or attachment. If a periodontal treatment is proposed to treat the recession, patients may express a fear of surgery or the associated fees for the required procedures.
- What are the dimensions of the gingiva? The health of the soft tissue is determined by the attachment height. This is determined by measuring the distance from the mucogingival junction to the fee gingival margin, and subtracting the sulcus depth. It is considered inadequate if it measures less than 1.5mm. If there is inadequate attachment height, grafting should be considered. The phenotype is another gingival dimension to be assessed. If the patient has a thin phenotype, less than 1mm thick, grafting should be considered to thicken the tissue as thicker tissue is more resistant to recession.
- What is the depth of the cervical lesion? The depth of the cervical lesion is determined by the loss of tooth structure in an axial direction (pulpally). If the depth is less than 2mm, periodontal treatment is the primary option to consider. If it is greater than 2mm, the deepest part of the cervical lesion may need to be restored with a glass ionomer or resin modified glass ionomer material.
- What is the depth of the recession? The depth of the recession is the amount of gingival recession in the coronal-apical direction. As the degree of recession increases, the greater the indication for periodontal treatment.
- Can the root be completely covered? The predictability of obtaining complete root coverage is primarily determined by Miller’s classification of recession. You can predictably achieve root coverage in Miller Class I and II recessions. You cannot achieve complete root coverage in Millar Class III and IV recessions because of loss of interproximal clinical attachment. A general rule when advancing tissue coronally is that the tissue can be advanced facially up to within 3mm of the papilla tip. When complete root coverage is not obtainable, a periodontal and restorative approach is suggested.
- Does the lesion involve the root only? If the cervical lesion involves only the root, periodontal treatment would be preferred. If the lesion involves the root and the anatomical crown, the crown should be restored and the root covered periodontally.
In addition to answering the six questions, the charts below will assist you in planning treatment for patients with gingival recession and cervical lesions:
- Allen, EP, Winter, RR. Interdisciplinary Treatment of Cervical Lesions. Compend Contin Educ Dent 2011; 32(5) 16-20.