(Click the links for earlier articles in this series: Part I, Part II, Part III, Part IV, Part V, Part VI and Part VII.)

This final article in the series focuses on a female patient who desires an esthetic improvement. She presents with significant recession and deep non-carious-cervical lesions undermining the CEJs on all the maxillary anterior teeth. In addition, she has lingual wear and a high smile line. (Figures 1 and 2)

soft-tissue grafting figure 1
soft-tissue grafting figure 2

Patients who present with isolated recession and a non-carious cervical lesion isolated to one tooth can be challenging. When all the maxillary anterior teeth present that way, it becomes an even bigger challenge. Often times the restorative dentist's approach to these patients is to restore the non-carious cervical lesions with composite, which is how this patient had been treated previously.

The problem with that approach is esthetically the teeth appear too long, and as all restorative dentists know, the longevity of these restorations can be very unpredictable. An alternative to composite is to perform an indirect ceramic restoration, extending the prep to include the non-carious cervical lesion, again resulting in teeth that are excessively long.

The more ideal approach is to consider soft-tissue grafting, attempting to coronally position the tissue to what would have been an ideal gingival margin position, although that is not always achievable. This is followed by restorations to cover any remaining exposed coronal portion of the non-carious cervical lesions.

Of course in addition to considering the treatment plan, it would be ideal to identify the etiology of both the recession and the non-carious cervical lesions, but I have to confess my belief that the etiology is often so multifactorial that claiming to know what caused it is probably not very accurate most of the time. I know those who love occlusion will happily say both the recession and NCCLs are occlusal issues, while those who believe heavily in abrasion will claim it is toothbrush and toothpaste related – and of course we shouldn't forget acid as another complicating factor.

What years of experience treating these patients has shown me is that if you cover all or most of the lesions with soft-tissue grafting, and the remaining coronal exposed portion with a restoration, these patients do remarkably well long-term – much better than if you just attempt to keep redoing restorations as they fail.

This patient represents a great example of the approach described, as the soft-tissue grafting using Alloderm, and a coronally positioned flap, brought the gingival margins to an almost ideal position esthetically with regards to tooth length. However, because of the extent of the destruction of the CEJs, it still left the coronal portion of the lesions exposed. (Figures 3, 4 and 5)

soft-tissue grafting figure 3
soft-tissue grafting figure 4
soft-tissue grafting figure 5

Because of the lingual wear, the condition of the teeth and the patient's esthetic desires, full-coverage indirect restorations were chosen instead of direct composite to cover the exposed coronal portion of the NCCL lesions. (Figures 6 and 7)

soft-tissue grafting figure 6
soft-tissue grafting figure 7

The final restorations for this patient were pressed lithium disilicate, cut back and layered with stacked ceramic for enhanced esthetics. The posterior restorations were metal ceramic with pressed ceramic over the copings to block out the dark underlying preps. The relatively good preparation color allowed for a facial reduction in the cervical region of 1 mm and subgingival margin placement of between .5-.7 mm below tissue. (Figure 8)

soft-tissue grafting figure 8

The anterior teeth were placed using a dual-cure dentin adhesive and dual-cure resin cement. The posterior teeth were placed with resin-modified glass ionomer cement. (Figure 9 and 10)

soft-tissue grafting figure 9
soft-tissue grafting figure 10

(Click this link for more dentistry articles by Dr. Frank Spear.)


Commenter's Profile Image Isabella T.
September 13th, 2019
How long is an adequate time to wait after the grafting has been completed to prepare the teeth? Do you leave the patients in provisional restorations longer in order to evaluate your margin placement and the stability of this tissue?
Commenter's Profile Image Frank S.
September 16th, 2019
Isabella, generally I wait 6 months following grafting before final margin placement. If I wait that long I don't leave the provisionals for an extended period. If I prepped and temped sooner, say 2 or 3 months, I would leave the provisionals until 6 months post surgery. Hope that helps. Frank