Treatment of noncarious cervical lesions: when, why, and how

16 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020

CLINICAL RESEARCH

Treatment of noncarious cervical

lesions: when, why, and how

Marleen Peumans, DMD, PhD

Associate Professor, Oral Health Sciences, BIOMAT, Catholic University Leuven, Belgium

Gianfranco Politano, DMD

Private Practice, Rome, Italy

Bart Van Meerbeek, DMD, PhD

Full Professor, Oral Health Sciences, BIOMAT, Catholic University Leuven, Belgium

Correspondence to: Prof Marleen Peumans

Oral Health Sciences, BIOMAT, Catholic University AA Leuven, Kapucijnenvoer 33, Leuven, 3000, Belgium;

Tel: +3216332744; Email: [email protected]

PEUMANS ET AL

1717

Abstract

Noncarious cervical lesions (NCCLs) involve the loss

of hard tissue from the cervical areas of teeth through

processes unrelated to caries. NCCLs are nowadays a

common pathology caused by changes in lifestyle

and diet. The prevalence and severity of cervical wear

increase with age. It is generally accepted that the le-

sions are not generated by a single factor but result

from a combination of factors. Among the factors

proposed to be related to the formation and progres-

sion of NCCLs are biocorrosion (erosion), friction

(abrasion), and possibly occlusal stress (abfraction).

The clinical appearance of NCCLs can vary depending

on the type and severity of the etiologic factors in-

volved. Practitioners should follow a checklist to

achieve an accurate diagnosis of the etiology of multi-

factorial NCCLs.

The successful prevention and management of NCCLs

require an understanding of the etiology and risk fac-

tors, including how these change over time in individ-

ual patients. The decision to monitor NCCLs rather

than intervene should be based on the progression of

the lesions and how they compromise tooth vitality,

function, and esthetics. Treatment options include

techniques to alleviate dentin hypersensitivity and the

placement of an adhesive restoration, eventually in

combination with a root coverage surgical procedure.

An adhesive restoration is considered the last treat-

ment option for NCCLs.

Based on their excellent esthetic properties and good

clinical performance, there is a general indication to

place composite restorations for NCCLs. The clinical

performance of these restorations is highly prod-

uct-dependent, particularly regarding the adhesive

system used. The type of composite material seems

to have no significant influence on the clinical perfor-

mance of NCCL restorations in clinical trials. It is much

more important that the operator carries out the clin-

ical procedure correctly.

Marginal degradation is frequently seen during aging.

Yearly maintenance with the eventual repolishing of

the restoration margins will lengthen the lifespan of

the restorations.

(Int J Esthet Dent 2020;15:16–42)

17The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 |

CLINICAL RESEARCH


Introduction

NCCLs are the result of a pathological con-

dition characterized by the loss of tooth

structure at the cementoenamel junction

(CEJ) that is unrelated to dental caries.1 The

occurrence of NCCLs is an increasingly

common finding in dental clinical practice.

This article aims to provide an up-to-date

summary of the prevalence, appearance,

and etiology of NCCLs. A checklist is pre-

sented to analyze the etiology of NCCLs.

Also discussed are treatment possibilities

based on current knowledge: prevention,

monitoring, alleviation of dentin hypersensi-

tivity, and treatment with an adhesive restor-

ation.

Prevalence

The prevalence of NCCLs has been report-

ed to vary between 5% and 85%.2,3 This large

variation can be attributed to the wide age

range of participants and the inclusion of

both genders in study populations as well as

the diverse criteria used to distinguish le-

sions caused by one precise etiologic fac-

tor.

A general finding is that prevalence, se-

verity, and progression of NCCLs increase

with age. This can be explained by extended

exposure to etiologic factors, increased oc-

currence of gingival recession and bone

loss with more root surface exposure (which

raises the risk of cervical lesions), diminished

quantity and quality of saliva, and composi-

tional and microstructural changes of

enamel and dentin.2,4,5

NCCLs are almost exclusively situated

on the facial surfaces of teeth; they seldom

occur on the lingual surfaces and rarely on

the proximal ones.

Fig 1 Extracted teeth showing different forms of NCCLs. (a) Cervical wear lesion

on a mandibular central incisor mainly caused by erosion. Notice the poorly

defined margins and adjacent smooth enamel surface. The lesion is most visible

at the buccal side but is also present at the proximal and lingual sides. (b) Very

deep NCCL with sharply defined margins on a maxillary premolar caused by a

combination of abfraction (wedge shaped) and abrasion (notice the horizontal

scratches in the depth of the lesion created by a toothbrush). The pulp is

retracted and the dentin in the depth of the lesion is brown, discolored, and

sclerotic. (c) U-shaped cervical wear lesion on a mandibular premolar caused by

a combination of erosion and abrasion. The scratch in the depth of the lesion,

created by the bristles of a toothbrush, is slightly smoothened by erosion.

(d) Abfraction wedge-shaped lesion on retaining primary canine with sharp

internal and external line angles and an apical extent relative to the CEJ. Notice

the severe occlusal wear facet, which suggests abnormal occlusal loading.

a

b

c

d

PEUMANS ET AL


Any tooth (incisor, canine, premolar or

molar) may exhibit an NCCL.3,5 Several epi-

demiological studies have reported that

premolars show the highest frequency of

lesions.6-9 In some studies, the most com-

monly affected teeth were mandibular pre-

molars,6,7 which also have the highest per-

centage of severe lesions.7

Appearance

Generally, NCCLs vary from shallow grooves

or lesions with poorly defined margins to

large wedge-shaped defects with sharp line

angles (Fig 1a to d).3,4 A link between the

morphological characteristics of lesions

and their main etiologic factor has been

suspected.

■ Disk-shaped broad and shallow lesions

with poorly defined margins and adja-

cent smooth enamel margins are con-

sidered to be the best predictive criteria

for the diagnosis of erosion as well as a

pathognomonic sign of erosive tooth

wear (Fig 1a). In young patients with cer-

vical erosive lesions, an enamel border is

often noticed at the gingival margin

(Fig 2a and b).

■ Lesions caused by abrasive forces such

as improper tooth brushing techniques

generally exhibit sharply defined margins

and a hard surface with traces of scratch-

ing (Figs 1b and 3).

■ Lesions caused by a combination of abra-

sion and erosion often have a U shape

(Figs 1c and 4).

■ Lesions caused by abfraction due to ab-

normal occlusal loading are typically

wedge shaped, with sharp internal and

external line angles, and an apical extent

relative to the CEJ (Figs 1d and 5).

Fig 2 (a and b) Generalized tooth wear in a 21-year-old bruxing patient who

drinks 3 liters of coca cola per day. Noncarious cervical active erosive lesions are

present on almost all of the buccal surfaces. The lesions are disk-shaped, broad,

and shallow, with poorly defined margins and adjacent smooth enamel areas.

Notice the defined enamel border at the gingival margins. All the teeth have

become shorter with time. The incisal/occlusal and palatal wear was caused by a

combination of erosion and bruxism, which can be destructive for the dentition.

All teeth showed hypersensitivity.

a

b

Fig 3 Cervical lesions on mandibular anterior incisors caused by an improper

tooth brushing technique. These typical abrasive lesions exhibit sharply defined

margins and a hard surface with traces of scratching. The mandibular incisors do

not make contact during habitual occlusion. Abfraction could have played a role

in the formation of the cervical wear lesions on the mandibular left canine and

first premolar.

CLINICAL RESEARCH


As there is overwhelming evidence that the

etiology of NCCLs is multifactorial, a combi-

nation of these different geometric forms

often presents (Figs 1b, 6, and 7).2-5

In general, the development of NCCLs

tends to be a slow process occurring over

an extended period of time, with pulpal re-

traction, sclerosis, and lack of dentin sensi-

tivity among the consequences (Figs 1b, 6,

and 7).10-12

Fig 4 NCCLs on teeth 32, 33, 34, and 36. The quite large lesions on teeth 33

and 34 are caused by a combination of abrasion (notice the presence of grooves

and gingival recession) and erosion (notice no sharp boundary of the lesion at the

enamel side). These lesions often have a U shape.

Fig 5 Full ceramic crowns were placed on the four incisors 20 years previously.

The patient is missing several posterior teeth. Notice the overeruption of teeth 11

and 12, which has resulted in abnormal occlusal loading on these teeth. Abfrac-

tion lesions are visible on teeth 11, 12, and 21. These lesions are typically wedge

shaped, with sharp internal and external line angles and an apical extent relative

to the CEJ.

A common complaint of patients with

erosive lesions is tooth hypersensitivity, an

unavoidable problem if the corrosive chal-

lenge continues. In these lesions, dentin

tubule exposure and enamel rod corrosion

are widely reported.11

Etiology

The development of a particular NCCL is

usually the consequence of a synergistic ac-

tion of two or three of the etiologic mech-

anisms unique to that individual case: bio-

corrosion (erosion), friction (abrasion), and

stress (abfraction) (Figs 6 and 7). In addition,

several risk factors can have an influence on

the formation of NCCLs: saliva, tooth form,

composition, microstructure, mobility, pos-

itional prominence, presence of restor-

ations, magnitude, direction, frequency,

site, and duration of the applied forces.4,13

Biocorrosion (erosion)

Biocorrosion of teeth can occur due to ex-

trinsic acids (acidic foods and drinks, acidic

mouth rinse, acidic medication) and/or in-

trinsic acids (gastric acid). In addition, pro-

teolytic enzymes present in the crevicular

fluid14 and proteolytic enzymes from the

stomach (pepsin) and pancreas (trypsin)15

released during vomiting can degrade the

demineralized dentinal organic matrix.

Risk factors are the composition and fre-

quency of the intake of acids, the position

and form of teeth in the dental arch, and the

presence of gingival recession. Saliva (pH,

viscosity, flow, composition, buffer capaci-

ty) is an important risk factor in the develop-

ment of NCCLs. The ions in saliva are able

to induce remineralization of demineralized

tooth structure and can thus inhibit the for-

mation of NCCLs.

NCCLs are more common on facial sur-

faces of teeth than on lingual ones. A possi-

ble explanation is the difference in chemis-

PEUMANS ET AL


try and character of saliva in lingual areas

(more serous saliva – higher buffer capacity)

and facial areas (mucous saliva – lower buf-

fer capacity), which accounts for the differ-

ences in remineralization of the tooth struc-

ture and the dilution of buffering acids.16

Xerostomia and dehydration from perspira-

tion with physical activity create impaired

salivary flow and inhibit the buffering of

acids in the oral cavity.

Friction (abrasion)

Friction or abrasion is the physical wear that

results from a mechanical process involving

foreign objects. Different factors can be in-

volved such as abrasive toothpaste, improp-

er tooth brushing using a horizontal tech-

nique and excessive force, frequency of

brushing, stiffness of bristles, and particular

dietary habits. The magnitude, direction, fre-

quency, and duration of the applied forces

are further risk factors in the development

of NCCLs. In addition, a prominent position

of the tooth in the arch leaves it prone to

excessive forces from tooth brushing.4,13

From results of laboratory and clinical stud-

ies, there is little evidence that NCCLs are

solely caused by abrasion.2

a b

Fig 6 (a and b) Cervical lesions on all mandibular anterior teeth caused by a synergistic interaction of over-occlusion of the anterior teeth

(abfraction), excessive tooth brushing (abrasion – notice the scratches on the surface of the lesion and gingival recession), and erosion. The

patient is a vegetarian, which suggests the influence of an abrasive and erosive factor. Brown, discolored sclerotic dentin is present on all the

lesions.

Fig 7 (a to c)

Generalized extensive

NCCLs in a 62-year-

old male patient.

Examination pointed

to a multifactorial

etiology. The occlusal

surfaces showed

wear facets with

erosive cupping. The

patient’s diet consists

of many abrasive

foods and he is

extremely fervent

when cleaning his

teeth, resulting in

extensive forces

being applied during

tooth brushing.

Notice pronounced

gingival recession and

a traumatized gingiva

in the maxillary

anterior region. The

cervical lesions in the

mandible are shallow-

er, probably because

of their more lingual

position. Sclerotic

dentin is present in

most lesions.

a

b

c

CLINICAL RESEARCH


Stress (abfraction)

The abfraction theory is based on a bio-

mechanical concept in which the cervical

area of a tooth becomes a fulcrum during

occlusal function, bruxing, and parafunc-

tional activity, causing tensile stresses in the

area where NCCLs occur. These stresses

are thought to disrupt the crystalline struc-

ture of the locally thin enamel and underly-

ing dentin by cyclic fatigue, leading to

cracks. Ultimately, the enamel breaks away

at the cervical margin and progressively ex-

poses the dentin, where the process contin-

ues.13,17 This theory is quite controversial.

Several finite element analysis (FEA) studies

have shown a clear correlation between oc-

clusion and NCCLs.18-22 In addition, several

clinical trials also report strong evidence of

an association between occlusal factors

and NCCLs (or their progression);23-26 never-

theless, two systematic reviews were unable

to show a clear association.27,28 The large

heterogeneity among methodologies, the

lack of standardization, and differences in

the diagnoses of NCCLs could contribute to

the weak evidence in these two reviews,

both of which concluded that prospective

clinical studies with a qualitatively and quan-

titatively strong study design are needed to

prove a clear association between occlu-

sion and NCCLs.

According to Grippo et al,13 some risk

factors can play a role in the development

of abfraction lesions. First, resultant stresses

within the teeth are dependent on the mag-

nitude, direction, frequency, site of applica-

tion, and duration of a force, in addition to

its orientation with respect to the principal

axes of the teeth and their form, composi-

tion, and stability. Second, the cushioning

effect of the periodontal ligament is another

modifying factor, as there is a negative cor-

relation between mobility and NCCLs. Third,

the weakening effect of an occlusal restor-

ation may contribute to the development of

an abfraction lesion. Finally, the occlusal

positional prominence of the teeth is anoth-

er important factor in determining possible

overstress and trauma (Fig 8).

Most lesions are caused by an interac-

tion of two or three causes that result in in-

creased cervical tooth wear, ie, the com-

bined effect of erosion and abrasion is

greater than the effect of either force oper-

ating on its own.29,30 It also appears that li-

quid acid, frequently found in modern diets,

may be necessary in order for occlusal load-

ing to be a factor in the formation of cervi-

cal lesions.31 In addition, it is suggested that

biocorrosion plays a very important role in

the formation of NCCLs.

Clinicians should consider all etiologic

and risk factors before completing the diag-

nosis or initiating treatment, if indicated.

Practitioners should follow a checklist to de-

termine the etiology of each particular lesion

in order to make as precise a diagnosis as

possible. Table 1 shows a simplified version

of the schema proposed by Grippo et al.13

Treatment options

To date, there is no conclusive evidence for

reliable, predictable, and successful treat-

Fig 8 This patient showed several NCCLs. The maxillary first molar extends

beyond the occlusal plane. Occlusal overstress resulted in additional cervical

wear due to abfraction in the mandibular second premolar and the maxillary first

molar.

PEUMANS ET AL


Biocorrosion – erosion

Chemical, biochemical, and electrochemical degradation of enamel and dentin

Check Etiologic factors Risk factors

Diet • Acidic beverages and foods

• Citrus fruits and juices

• Composition and frequency of

intake of acidic foods and drinks

• Buffering capacity, composition,

flow rate, pH, and viscosity of

saliva

• Position and form of the teeth

in the dental arch

• Gingival recession

Profession • Wine tasting

• Occupational exposure to acidic

industrial gases

• Activities resulting in dehydration

(eg, sport activities)

Medical history • Gastroesophageal disease with reflux

• Anorexia or bulimia nervosa

• Factors predisposing the patient to

gastric reflux (eg, hiatus hernia, sport

activities)

• Acidic medication (eg, Vitamin C)

• Acidic mouth rinses

• Medication that decreases salivary

flow

Abrasion – friction

Physical wear as a result of a mechanical process involving foreign objects

Diet Mastication of coarse foods

Oral hygiene

practices

• Abrasive toothpaste

• Tooth brushing technique

• Stiffness of toothbrush bristles

• Frequency of brushing

• Incorrect hygiene habits

• Magnitude, direction, frequen-

cy, site, and duration of force

applied during tooth brushing

• Position and form of the teeth

in the dental arch

• Gingival recession

Dental appliances Clasps of prostheses

Abfraction – stress

Tensile stress at the cervical area during occlusal loading

Occlusal

examination

• Parafunction (eg, bruxism, clenching)

• Excessive functional load

• Malocclusion

• Premature contacts

• Eccentric loading

• Habits (eg, biting on hard objects)

• Mastication of hard and resistant food

substances

• Magnitude, direction, frequen-

cy, site, and duration of the

applied forces

• Mobility of the teeth

• Presence of occlusal restor-

ations

Table 1 Etiology of

NCCLs – checklist

CLINICAL RESEARCH


ment regimens for NCCLs. The current

knowledge and available treatment strat-

egies for NCCLs are discussed below, with a

focus on prevention, monitoring, treatment

of dentin hypersensitivity, restorative treat-

ment, and root coverage surgical proced-

ures with or without restorative treatment.

Prevention

The objectives of preventive therapy are to

prevent the progression of existing lesions

or the development of new ones and to as-

sure the longevity of restorations in restored

lesions. Preventive interventions include

counseling for changes in the patient’s be-

havior depending on the etiology (abrasion,

erosion, and/or abfraction).4,13,32

Cervical abrasions are generally thought

to be a consequence of tooth brushing fac-

tors such as frequent or forceful brushing,

faulty or vigorous techniques, filament stiff-

ness or design, dominant hand dexterity, or

abrasive dentifrices. Patients should be in-

formed about these factors and, where nec-

essary, advised to alter their brushing mater-

ials or habits. In addition, patients should be

instructed to avoid brushing immediately

after an erosive challenge.

Dental erosion can also be effectively

modified and should be correctly diagnosed.

Treatment success depends on the patient’s

collaboration.4,13 When erosion is caused by

eating disorders or gastroesophageal reflux

disease, the treatment may require the par-

ticipation of a physician. The extrinsic etiolo-

gy is more easily treatable. During the diag-

nostic phase, the checklist (Table 1) must be

followed to see which external erosive fac-

tors exist. Removing or altering harmful

habit/s provides consistent results.

For NCCLs with an abfraction etiology,

there is no consensus on preventive treat-

ment strategies. On the one hand, there is a

weak association between NCCLs and oc-

clusal factors (interference in excursive

movements, force, premature contacts,

type of guidance, and slide of centric occlu-

sion to maximum intercuspation). In two

systematic reviews,27,28 several authors ad-

vise that any decision to carry out a destruc-

tive, irreversible treatment such as occlusal

adjustment should be considered very care-

fully.1,4,5,28 If abfraction is suspected to be a

dominant factor in the etiology of NCCLs,

the most conservative treatment option

suggested is an occlusal splint as this re-

duces the amount of nocturnal bruxism and

nonaxial tooth forces,4,5 although in this

case too there is no scientific evidence to

support the use of an occlusal splint. On the

other hand, Soares and Grippo33 state that

preventive management strategies should

consider occlusal therapy in patients with

parafunctional habits and occlusal prema-

turities. According to these authors, occlu-

sal therapy can mitigate the development of

NCCLs by correcting occlusal imbalance

and removing occlusal prematurities. They

emphasize that occlusal therapy must be

carried out with a thorough knowledge of

the occlusion.

Monitoring

The activity of NCCLs needs to be assessed

and considered in the treatment planning

process. It is known that the progression of

NCCLs is generally slow, but with a large

variation among patients.26,34,35 Therefore,

an individual monitoring protocol should be

established that assesses the severity of the

present lesions, the patient’s age, and the

existing etiologic and risk factors. For pa-

tients who are exposed to intrinsic acids or

who present with rapid progression, the as-

sessment procedure of lesion activity should

be repeated at 6-month intervals during

regular hygiene. For most other cases, an-

nual assessment is acceptable (Fig 9).

Approaches to determine lesion activity

include the use of standardized intraoral

PEUMANS ET AL


photographs, possibly study models, and

the measurement of lesion dimensions

(width/length) over time. With the recent in-

troduction of digital dentistry, comput-

er-aided design/computer-aided manufac-

turing (CAD/CAM) systems may be useful

for the diagnosis of NCCLs and in monitor-

ing their activity.

In a prospective clinical trial evaluating

the progression of NCCLs over a 5-year

period, the rate of progression was signifi-

cantly related to mean occlusal stress and

relative occlusal force in the maximum in-

tercuspation position.26 No significant cor-

relation was found between NCCL progres-

sion and a more acidic diet, tooth brushing

technique/rigorousness, medical conditions

causing deficient or acidic saliva output,

presence of occlusal wear facets, group

function, or adverse oral habits. Moderate

sensitivity on the involved teeth was found

in 34.5% of the participants by using the cold

test. A moderate to high degree of sclerosis

was observed on 68.9% of the lesions.

In another in vivo study evaluating 10 le-

sions in six patients over a period of 4 to

5 years, dimensional analysis showed nota-

ble progression in deeper lesions.35 In addi-

tion, wedge-shaped lesions were reported

to progress at a greater rate compared with

saucer-shaped ones. The same observation

was made in an in vitro study using 3D FEA.20

V-shaped lesions showed higher stress lev-

els concentrated at the zenith of the lesion,

whereas in U-shaped defects the stresses

were concentrated over a wider area. As the

lesions advanced in depth, the stress was

amplified at their deepest part. A trend of

stress amplification was also observed with

decreasing bone height.

One should bear in mind that restorative

treatment may be indicated at an earlier

stage for V-shaped lesions than for U-shaped

ones in patients with a heavy occlusion

and articulation. Restoring deeper (1.5 mm)

NCCLs is usually prioritized over shallower

ones due to the higher stress development

of deeper lesions that results in their more

notable progression.

Treatment of dentinal hypersensitivity

Dentinal hypersensitivity is a symptom often

associated with early stages of NCCLs. If the

lesions are small and shallow and require no

restorative treatment, and should sensitivity

persist, the hypersensitive tooth must first

be treated in a noninvasive way. There is a

broad spectrum of relatively cost-effective

at-home desensitizing agents available on

Fig 9 (a and b) Several small NCCLs in the posterior region in a 35-year-old

patient due to a combination of abfraction and abrasion. The patient showed

signs of bruxism for which an occlusal splint was made. As the lesions were

stable during the yearly follow up, no treatment was needed.

a

b

CLINICAL RESEARCH


the market that show different mechanisms

of action: nerve desensitization (eg, potassi-

um nitrate), protein precipitation (eg, glutar-

aldehyde, silver nitrate, zinc chloride, stron-

tium chloride hexahydrate), and plugging

the dentin tubules (eg, sodium fluoride,

stannous fluoride, strontium chloride, po-

tassium oxalate, calcium phosphate, calci-

um carbonate, bioactive glass).36 These

agents include toothpastes, mouth washes

and chewing gums. The results of at-home

desensitizing therapy should be reviewed

after 3 to 4 weeks. If there is no relief from

dentinal hypersensitivity, in-office therapy

should be initiated. Recently, the in-office

application of calcium- and phosphate-

based systems was introduced to decrease

hypersensitivity and promote remineraliza-

tion of the tooth surface, eg, Teethmate De-

sensitizer (Kuraray Noritake) (Fig 10) and air

polishing with Sylc Bioactive Glass (Velopex)

(Fig 11a to d).37-39 These products react with

body fluids and result in the formation of hy-

droxyapatite (HAp) crystals, similar to the

minerals in dentin, which block the dentinal

tubules. Both systems show promising re-

sults; however, confirmation in clinical trials

is required.

Finally, resin-based dental adhesive sys-

tems can also provide a longer-lasting den-

tin-desensitizing effect compared with the

use of home-desensitizing agents.4,5,36,40 The

adhesive resins can effectively seal the den-

tinal tubules by forming a hybrid layer. Vari-

ous clinical studies have demonstrated the

effectiveness up to 6 months of adhesives

in the management of dentin hypersensitiv-

ity.40,41

Restorative treatment

Restorative treatment of NCCLs should be

considered when one or more of the fol-

lowing conditions are present: 1) active,

cavitated caries lesions associated with

NCCLs; 2) cervical lesion margins or all le-

sion margins are located subgingivally and

preclude plaque control, hence the risk of

caries and periodontal disease increases;

3) extensive tooth structure loss, which

compromises the integrity of the tooth, or

the defect is in close proximity to the pulp,

or the pulp has been exposed; 4) persistent

dentinal hypersensitivity in which noninva-

sive therapeutic options have failed; 5) pros-

thetic abutment for removable prosthesis;

and 6) esthetic demands by patients.5,32 If

there is a need for a restoration, NCCLs

should be restored as minimally invasively

as possible. Of the available restorative tech-

niques, an adhesive system, combined with

a composite resin, is the preferred choice of

practitioners due to the good esthetic prop-

Fig 10 In-office treatment of hypersensitive dentin with Teethmate Desensitizer

(Kuraray Noritake). (a) Isolate the tooth and dry the tooth surface. (b) Mix the

powder and liquid according to the manufacturer’s instructions and apply the

slurry for at least 30 s. Rinse off with water spray or allow the patient to rinse.

a

b

PEUMANS ET AL


a

b c

d

Fig 11

patient with extensive

cervical abrasion

lesions on all her

teeth. The exposed

dentin surfaces

showed hypersensi-

tivity. At-home

desensitizing therapy

did not give relief

from hypersensitivity.

Therefore, in-office

therapy – air polishing

with Sylc Bioactive

Glass (Velopex) – was

planned. (b and c)

After local anesthesia,

air polishing of the

exposed root

surfaces with

bioactive glass was

carried out, using a

pressure of 4 to 5

bars with water spray

1 to 2 mm away from

the surface. The

orientation of the

spray is 45 to 90

degrees. The action is

to move slowly for

about 30 to 60 s, as if

painting the surface.

(d) Air polishing with

bioactive glass

resulted in a serious

reduction in dentin

hypersensitivity. In a

next step, cervical

composite restor-

ations will be placed,

followed by a root

coverage surgical

procedure (CTG and

CAF).

CLINICAL RESEARCH


erties and clinical performance of compos-

ite resin (Fig 12). Although glass-ionomers,

resin-modified glass-ionomers, and the lam-

ination technique with composite resin have

been advocated for NCCL restorations, these

materials are less frequently used.42,43

Adhesively restored NCCLs can perform

quite well in the long term (Fig 13).43 Several

parameters determine the clinical behavior

of these restorations. According to a sys-

tematic review evaluating the clinical ef-

fectiveness of contemporary adhesives in

NCCLs, the selection of the adhesive sys-

tem is an important factor determining the

durability of the restoration.43 Apart from the

selection of the adhesive system, the oper-

ator plays a decisive role. The operator has

to take care that a high-quality clinical pro-

cedure is carried out: isolation, tooth prep-

aration, application of the adhesive system

and composite, finishing, polishing, and fi-

nally maintenance of the restoration. These

different parameters are successively dis-

cussed in detail below.

Selection of the adhesive system

According to the classification of Van Meer-

beek et al,44,45 modern adhesive approaches

can be divided into etch-and-rinse adhe-

sives (E&Ra), self-etch adhesives (SEa), and

restorative materials with a self-adhesive ap-

proach (Fig 14).

The multi-step etch-and-rinse approach

involves a phosphoric acid-etch step that at

the enamel level produces deep etch pits in

the HAp-rich substrate, and at the dentin lev-

el demineralizes up to a depth of a few mi-

crometers to expose a HAp-deprived colla-

gen mesh. The next step involves either a

separate priming step followed by the appli-

cation/curing of a combined primer/adhe-

sive resin using a 2-step procedure (2E&Ra),

or a separate primer and adhesive resin fol-

lowing a 3-step procedure (3E&Ra). The final

objective is to micromechanically interlock

Fig 12 (a) A 70-year-old female patient showing NCCLs on all her mandibular

anterior teeth. The etiology was multifactorial, with abrasion being the main

etiologic factor. The exposed dentin was not hypersensitive. The reason for the

treatment with direct composite restorations was to improve esthetics. (b) Apart

from the small lesion on tooth 43, all the NCCLs were restored with a nanohybrid

composite in combination with a mild 2SEa.

Fig 13 Two mandibular premolars with 20-year-old Class V composite restor-

ations. A 3E&R adhesive system was used in combination with a microfilled

composite (first premolar) and a hybrid composite (second premolar). After

20 years, the restorations are still clinically acceptable, presenting slight marginal

defects and superficial marginal discoloration.

a

b

PEUMANS ET AL


upon diffusion and in situ the polymerization

of monomers into the enamel etch pits, the

opened dentin tubules, and the exposed

collagen network, the latter forming the

well-documented hybrid layer.44,45

Self-etch adhesives use non-rinse acidic

monomers that simultaneously condition

and prime dentin. Self-etching only dis-

solves the smear layer but does not remove

the dissolved calcium phosphates as there

is no rinse phase. The clinical application

time is shorter, and technique-sensitivity is

reduced. In addition to a 2- and 1-step pro-

cedure (2SEa, 1SEa) – depending on the use

or not of a separate solvent-free bonding

agent – a further distinction can be made

depending on the pH of the self-etching

primer: strong: (pH < 1) (SEa_s), intermedi-

ate (pH ± 1.5), mild (pH ± 2), and ultra-mild

(pH ≥ 2.5). The latter three groups (interme-

diate, mild, ultra-mild, named below as

SEa_m) do not demineralize the dentin sur-

face completely, and HAp will be left in the

hybrid layer. The functional monomer (eg,

4-MET, 10-MDP, phenyl-P) present in the

self-etching primer has the possibility of

chemically interacting with the HAp.46 This

results in a twofold micromechanical and

chemical bonding mechanism. Of all com-

mercially available functional monomers,

10-MDP has been proven to be the most

effective one, able to form a stable and du-

rable chemical bond with HAp in the hybrid

layer.47 E&Ra and SEa are combined with a

restorative material (a composite resin, a

giomer or a compomer).

Glass-ionomers (GIs) and resin-modified

GIs are self-adhesive materials. A short poly-

alkenoic acid pretreatment is recommend-

ed, resulting in a 2-step approach. The poly-

alkenoic acid conditioner cleans the tooth

surface. It removes the smear layer and ex-

poses collagen fibrils up to a depth of about

0.5 to 1 μm, where GI components inter-

diffuse and a micromechanical bond is es-

tablished following the principle of hybrid-

ization. Chemical bonding is additionally

obtained by ionic interaction of the carboxyl

groups of the polyalkenoic acid with the

calcium of the HAp that remains attached to

the collagen fibrils. Most of the glass-iono-

mers and resin-modified glass-ionomers are

available as restorative materials.

Other self-adhesive materials are the so-

called self-adhesive luting composites, most

of which are available as luting agents.

Self-adhesive flowables were introduced

onto the dental market some years ago, but

the in vitro bonding efficiency to tooth

structure is below the level of that recorded

for the commonly used adhesive systems

described above.48

Nowadays, there is a major trend to use

universal adhesives, which are actually a

Fig 14 Classification of contemporary adhesives according to Van Meerbeek

et al.44,45

CLINICAL RESEARCH


newer version of 1SEa_m that can be applied

in different modes: an etch-and-rinse mode,

a self-etch mode, and a self-etch mode with

prior selective etching of the enamel margin

with 35% phosphoric acid.49,50

NCCLs are the most ideal lesions to test

the clinical effectiveness of adhesives in clin-

ical trials.43 These lesions involve both enam-

el and dentin; however, the largest part of

the tooth structure on which to bond con-

sists of dentin. These lesions commonly do

not provide any (or they provide minimal)

macroretention, so ineffective bonding will

result in debonding and thus restoration

loss. Loss of retention is the key objective

parameter against which the bonding per-

formance of adhesives in NCCL clinical trials

is evaluated. In a systematic review of NCCL

clinical trials, the number of lost restorations

per year (calculated as annual failure rate

[AFR]) was recorded in 87 clinical trials evalu-

ating 78 different adhesives.43 The adhesives

were classified into seven different classes:

3E&R, 2E&R, 2SEa_m; 2SEa_s, 1SEa_m,

1SEa_s, and GI. SEa_m contains the inter-

mediate, mild, and ultra-mild SEa (described

on the previous page). The first conclusion

was that the adhesive strategy is a determin-

ing factor for the clinical bonding effective-

ness in NCCLs. The best-performing classes

were GI, with the lowest AFR score, followed

closely by 2SEA_m, 3E&R, and 1SEA_m. An

inadequate bonding effectiveness was no-

ticed for 2E&Ra, 1SEa_s, and 2SEa_s. It is

obvious that the chemical bonding poten-

tial of adhesives is important for the quality

and durability of the bond in NCCLs. In ad-

dition to the adhesive strategy, a wide varia-

tion exists between the adhesives them-

selves. Practitioners should therefore select

a product that has a good proven clinical

performance. In the best-performing adhe-

sive categories described above, the lowest

AFR scores were recorded for Optibond FL

(Kerr) for 3E&Ra, Clearfil SE Bond (Kuraray

Noritake) for 2SEa_m, and G-Bond (GC) for

1SEa_m. These results accord with those of

a systematic review that evaluated the bond-

ing effectiveness of adhesives in vitro ac-

cording to microtensile bond strength

tests.51 Similarly, Optibond FL and Clearfil SE

Bond showed the best results regarding im-

mediate bond strength and bond strength

after 1 year of water storage.

Although GI-based materials perform

well with regard to retention, their rather

poor esthetic properties, inferior wear resis-

tance, and solubility particularly in acidic

oral environments may make them less ad-

equate for restoring NCCLs, especially in

the anterior and premolar regions.42,43

Isolation

Proper isolation is important for the success

of NCCL restorations. A recently published

meta-analysis stated that the use of rubber

dam positively influences the performance

of adhesive NCCL restorations, resulting in

less retention loss and better marginal adap-

tation.52 Therefore, if the clinical situation al-

lows, absolute isolation with rubber dam

should be applied. A good strategy has to be

followed, with the practitioner aware of the

tips and trips to correctly isolate under rub-

ber dam.53 For this procedure, the use of

heavy rubber dam is preferred as it results in

the best retraction of the peripherical tissues,

including the papilla. The holes must be

punched correctly so that all gingival tissues

are covered. Inverting the rubber dam around

the neck of the tooth prevents the saliva

from leaking in between the rubber dam and

the gingiva. Useful clamps for rubber dam

isolation of NCCLs are the Brinker Clamps

(Tissue Retractors) (B4, B5, B6) (Hygenic;

Coltene Whaledent) and Clamp 212 (Hu

Friedy). In addition, floss, teflon tape, and gin-

gival retraction cord can be used to obtain

additional gingival retraction (Figs 15 and 16).

Intrinsic anatomical and morphological

characteristics of the cervical region can cre-

PEUMANS ET AL


ate limitations in the placement of the rubber

dam and clamp. Difficulties can occur, for

instance, when restoring a NCCL on a molar

or on other teeth with a very large difference

in height between the buccal and lingual gin-

giva or when teeth are severely crowded.

When adequate rubber dam isolation is

not possible, another isolation method

should be employed. The insertion of a gin-

gival retraction cord in combination with

cotton rolls can help to control moisture. A

blood and hemostatic agent can be used

when needed to control blood contamina-

tion. Some studies have demonstrated that

dentin contamination with ferric sulfate or

aluminum chloride decreases the bond

strength of self-etch adhesives.54,55 Groddeck

et al56 showed that cavity contamination with

hemostatic agents, applied after blood con-

tamination and removed with water spray,

does not compromise marginal adaptation

in enamel and dentin when using an E&Ra or

an SEa,56 although element surface analysis

showed that remnants of hemostatic agents

were found on enamel and dentin surfaces

after rinsing the dark coagulum with water

spray. Apparently, remnants of hemostatic

agents on the surface of dental hard tissues

might have less influence on marginal adap-

tation than on bond strength. A last option is

a proposed association of a plastic or metal

matrix with wooden wedges and a photo-

cured gingival barrier.57

Fig 15 (a and b)

Teeth 31 and 44:

Isolation with rubber

dam and rubber dam

clamp (Brinker B5

from the Brinker

Tissue Retractor Set;

Hygenic). After

placing the clamp,

the cervical margin

becomes clearly

visible.

Fig 16 (a) Tooth 31:

Additional retraction

was realized with

teflon tape. Regard-

ing tooth preparation,

a short enamel bevel

(1 to 2 mm) was

made with a

diamond bur. The

dentin surface was

roughened with a

small round

diamond bur. The

sharp area in the

depth of the lesion

was smoothened.

(b) Air abrasion of the

roughened enamel

and dentin surface

with Al2O

3 (27 μm)

(Aquacare; Velopex)

resulted in a clean

prepared tooth

surface. The

adjacent teeth were

protected with a

metal matrix band.

a b

Tooth preparation

Preparation of the enamel side

At the incisal side, the composite material

will be bonded to enamel. A short enamel

bevel (1 to 2 mm) should be prepared using

a microfine diamond bur (Fig 16a). This re-

a

b

CLINICAL RESEARCH


moves the aprismatic enamel and increases

the bond strength to enamel.58 In addition,

placement of an enamel bevel will result in

a more gradual transition between the com-

posite restoration and tooth surface, improv-

ing the final esthetic outcome.

Preparation of the dentin surface

The dentin surface of NCCLs is often scle-

rotic and is a more difficult substrate to

bond to than sound dentin. Sclerotic dentin

is hypermineralized and has a shiny and firm

appearance. The dentin tubules are partially

or completely occluded by mineral depos-

its, resulting in a higher resistance to acid

dissolution. Morphological evaluation of the

resin–sclerotic dentin interface shows a thin

hybrid layer at the hypermineralized intertu-

bular dentin, and short and barely devel-

oped resin tags.59

To increase the bonding effectiveness to

this type of dentin, the superficial sclerotic

dentin should be roughened with a dia-

mond bur (Fig 16a).52 Another important rea-

son to roughen the dentin surface is to re-

move the contaminated layer observed on

most NCCLs during microscopic evaluation

of extracted teeth (Fig 17).11,60 This layer re-

sists adhesion and should therefore be re-

moved.

The roughness of the diamond bur is im-

portant as this can influence the thickness of

the smear layer. The creation of a thick smear

layer can interfere with the bonding efficien-

cy of mild/ultra-mild (pH ≥ 2) self-etch adhe-

sives.61 Therefore, to ensure a clean rough-

ened tooth surface with a minimal thickness

smear layer, tooth preparation should be fi-

nalized using airborne-particle abrasion with

Al2O

3 powder (27 or 50 μm) (Fig 16 b). Air

abrasion is reported to increase the surface

area available for adhesion, improve resin ad-

aptation, and enhance resin tag forma-

tion.62-64 Several in vitro studies have shown

an increased bond strength to dentin when

using an E&Ra or SEa.63-66 Other in vitro stud-

ies, however, measured no significant influ-

ence of air abrasion on the bond strength to

enamel and dentin (also for E&Ra and SEa),69

not even after aging.69

In general, the preparation must be kept

as minimally invasive as possible by only

roughening the enamel and dentin surfaces.

However, in sharp, wedge-shaped NCCLs in

teeth with heavy occlusal loading, rounding

the depth of the angular lesion can be justi-

fied to improve the biomechanical behavior

of the restorative material and consequently

promote clinical longevity (Fig 16).18,19

Application of the adhesive system

The adhesive system must be applied strict-

ly according to the manufacturer’s instruc-

tions (Figs 18 to 20). When using a non-sim-

plified adhesive (3E&Ra, 2SEa), the primer

must be applied vigorously and rigorously

to the dentin surface for the amount of

time indicated by the manufacturer. An op-

timized wetting and penetration of the ex-

posed dentin surface will result in the for-

mation of a good-quality hybrid layer. The

importance of this step is often underesti-

mated.

When using a mild SEa system, the best

clinical performance will be obtained when

the incisal enamel is selectively etched with

35% phosphoric acid (Fig 18). Small marginal

Fig 17 After isolation with gingival retraction cords and cotton rolls, the

contaminated layer on the dentin surface of the NCCLs is clearly visible. This

layer must be removed by roughening with a diamond bur or with Al2O

3 (27 μm)

to create a clean dentin surface that is perceptible for a good-quality adhesive

bond.

PEUMANS ET AL



Selective enamel

etching of the

prepared enamel

with phosphoric acid

(35%) for 20 s to

optimize the bonding

at the incisal enamel

side. (b) After rinsing

with water and

drying, a dull-etched

enamel surface is

clearly visible.

a b


Application of a

10-MDP-containing

self-etching primer

(Clearfil SE Bond 2;

Kuraray) for 20 s.

(b) The primed

surface was air dried

gently and slightly

until a dull surface

was noticed.

a b

Fig 20 (a and b)

Teeth 44 and 31: The

adhesive was applied,

air thinned, and light

cured for 10 s.

a b

CLINICAL RESEARCH


defects and superficial marginal discolor-

ation will present less frequently at the incisal

enamel side with aging.43 Etching enamel

with phosphoric acid creates a deeper and

more pronounced etch pattern compared

with SEa and results in an increased micro-

mechanical retention and a more optimal

bond to enamel.

Selecting a universal adhesive, a 10-MDP-

based adhesive is preferred, used in a self-

etch mode with prior selective etching of

the enamel. The chemical interaction be-

tween the 10-MDP functional monomer

and calcium is only possible when HAp re-

mains in the hybrid layer. All HAp is dissolved

when one follows the E&R approach.

Finally, when using a simplified adhesive

system, it is best to cover the adhesive with a

hydrophobic resin coating. The use of this ad-

ditional coating after the application of a sim-

plified adhesive system leads to a thicker and

more uniform adhesive layer with less re-

tained water and solvent and a significant re-

duction in the fluid flow rate. In this way, a

more stable resin–dentin interface is formed.43

Selection and application

of the composite

Selection of the composite

NCCLs have a relatively small C-factor,

meaning that the mechanical properties of

the composite are less important to the out-

come of the final restoration than the actual

performance of the adhesive. Indeed, sever-

al reviews have shown that the type of com-

posite used had no influence on the bond-

ing performance of adhesives in NCCLs.42,43,70

Similarly, compomers and giomers, both

fluoride-releasing resin materials, do not

show a better performance compared with

conventional composites in NCCL clinical

trials.42,43

It has been stated that NCCLs suspected

of being caused primarily by abfraction

should be restored with a microfilled resin

composite or a flowable resin that has a low

modulus of elasticity because these will flex

with the tooth and not compromise reten-

tion. However, no definitive conclusion can

be found in the literature that addresses the

difference between failure rates of resin

composites of different stiffness used to re-

store NCCLs.71,72

Application of the composite

A multiple layering technique with a con-

ventional composite has been proposed to

restore deeper and/or larger lesions to min-

imize shrinkage due to polymerization and

also to achieve better marginal adaptation

in Class V non-carious lesions. Several in vi-

tro studies70,73,74 have shown that the best

results are obtained when using the oblique

layering technique from gingival toward in-

cisal. This technique has been applied in

most NCCL clinical trials.43 Indeed, since

enamel adhesion is stronger, more stable,

and more predictable, the insertion of ma-

terial should begin from the gingival wall,

without the surrounding enamel. Whenever

possible, the cavity should be restored with

three or two increments (Figs 21 to 25). The

last one should be placed on the enamel

margin. Small lesions can be restored with

one increment.

An alternative application method is to

cover the entire exposed dentin surface

with a thin layer of flowable composite in a

first step to optimize the adaptation of the

composite to the hybridized dentin surface.

In addition, the lower e-modulus and higher

flexibility of the flowable composite will

compensate for polymerization shrinkage.

Next, the rest of the lesion should be re-

stored with a stiffer conventional composite

(Figs 24 and 25).

As far as esthetics is concerned, the col-

or of the cervical area is easy to obtain. The

use of a medium opacity chromatic dentin

composite covered with a more translucent

slightly chromatic enamel composite – also

PEUMANS ET AL


Fig 21 (a) Tooth 44: Application of a chromatic dentin composite covering the dentin surface (Essentia Dark Dentin; GC) followed by

polymerization. (b) Next, a translucent enamel composite with low chromaticity, also called achromatic enamel75 (Essentia Dark Enamel) was

applied to restore the contour of the tooth. This layer covers the incisal enamel bevel.

a b

Fig 22 (a) Application of glycerine gel and final polymerization (20 s) to eliminate the oxygen-inhibited layer. (b) The restorations were

checked 1 week after final finishing and polishing.

a b

CLINICAL RESEARCH


Fig 23 NCCLs on teeth 44, 42, 41, and 31 (a) before and (b) after placement of direct composite restorations.

a b

Fig 24 NCCLs on teeth 34 and 35 (a) before and (b) after restorative treatment with direct composite restorations.

a b

Fig 25 (a) Tooth 35: Application of the adhesive system. (b) A thin layer of flowable composite was applied over the whole dentin surface

and polymerized. (c) A conventional microhybrid composite was placed to restore the original contour, starting from the cervical third and

covering the incisal enamel margin.

a b c

PEUMANS ET AL


called achromatic enamel75 – copies the

natural tooth structure (Figs 21 to 23). Most

practitioners prefer a simplified color build

up and use just one chromatic body com-

posite with medium opacity.

A careful placement technique is need-

ed to minimize the finishing procedure.

Finishing and polishing

Any excess or roughness should be avoided

in NCCL restorations. Plaque retention, gin-

gival inflammation, and the occurrence of

caries lesions represent not only a failure of

the restoration but also a creation of new

problems for the patient. Poorly performed

finishing and polishing procedures can lead

to soft and hard tissue damage. Techniques

that require a minimal amount of finishing

and polishing are ideal, but properly con-

toured restorations are seldom achieved

without removing excess material, especial-

ly at the margins. When needed, a good op-

tion is to use a microfine diamond finishing

point (40 μm grit size), then a coarse com-

posite finishing disc, and finally the applica-

tion of rubber polishing points with a de-

creasing grit size (Fig 26).

When a Class V restoration is performed

in a semi-direct way, as described by Fahl76

and Ritter et al,77 the composite restoration

is made and finished extraorally and is then

bonded with a luting composite. The extra-

oral finishing and polishing of these Class V

inlays simplify the finishing procedure of the

restoration after cementation. According to

these authors, this technique more easily

provides a high surface smoothness and a

good marginal adaptation compared with

the commonly used direct technique. How-

ever, clinical studies are required to prove

whether this technique is superior to the

clinically proven direct technique.

Maintenance

The condition of the restorations must be

evaluated yearly. Marginal deterioration that

presents as marginal discoloration and small

marginal defects is commonly seen in these

restorations with aging;43,78 their lifespan can

be lengthened by repolishing the restor-

Fig 26 Finishing and polishing of NCCL composite restorations. (a) Using a microfine pointed diamond bur (40 μm). (b and c) Finally,

polishing with rubber polishing points with a decreasing grit size.

a b c

CLINICAL RESEARCH


ation margins (Fig 27). If larger defects are

present, local repair is indicated.

The influence of the patient factor on

the clinical performance of the restorations

should not be underestimated. As already

mentioned, the etiology of the NCCLs must

always be kept under control to prevent re-

currence of the lesions. Importantly, special

conditions such as poor oral hygiene, high

caries risk, heavy bruxism, and erosive chal-

lenges were not included in most NCCL

clinical trials. Although one expects that

these high-risk patient factors negatively in-

fluence the lifespan of the restorations to a

large extent, the clinical longevity of resin

composites as restorative materials in such

a context has not yet been clinically investi-

gated.

Root coverage surgical procedures in combination with a restoration

NCCLs may be associated with gingival re-

cession, exposing root surfaces to the oral

cavity. Placement of a composite restor-

ation is possible, but the esthetic result can

be disappointing. If esthetics is important to

the patient, the ideal treatment for the

combination of noncarious cervical lesions

(particularly in the case of deep lesions) and

gingival recession is a combined perio-

restorative approach (Fig 28).32,79,80 In a com-

bined restorative-surgical approach, the res-

toration must be placed prior to the surgical

procedure for better visibility of the opera-

tive field and for the finished restoration. To

properly restore the dental tissue lost due to

wear, the maximum level of root coverage

needs to be predetermined.79,80

The restoration should recreate not only

the contour of the tooth crown but also that

of the lost CEJ at the root portion. Recent

systematic reviews have pointed out that

the combination of a coronally advanced

flap (CAF) with connective tissue graft (CTG)

provides the best clinical outcomes for root

coverage when appropriately performed.79,80

However, there is still a lack of long-term

clinical evidence to prove the stability of the

combined perio-restorative approach.

Conclusion

To achieve an accurate diagnosis of the eti-

ology of multifactorial NCCLs, practition-

ers should follow the following checklist:

comprehensive medical and dental history,

occlusal examination, evaluation of diet,

and oral hygiene procedures. Furthermore,

important risk factors in the formation of

NCCLs should be taken into account.

Treating NCCLs necessarily involves

problem identification, diagnosis, etiologic

factor removal, monitoring, and, if neces-

sary, treatment. Personalized treatment

Fig 27 (a) A female patient requested the replacement of cervical composite restorations due to discolored

margins. (b) Repolishing the restoration margins removed the superficial discoloration, thus increasing the longevity

of the restorations.

a b

PEUMANS ET AL


Fig 28 (a) Initial

situation: A 50-year-

old female patient

showed gingival

recession on the

maxillary anterior

teeth and deep

cervical lesions on

the maxillary

premolars and first

molars. The patient

requested an esthetic

improvement. The

deep defects on

teeth 14, 15, 16, and

26 were first restored

with direct compos-

ite restorations until

the level of the CEJ.

(b) Initial situation:

Lateral view, with

NCCLs on several

teeth. (b) After

placement of direct

composite restor-

ations on teeth 14, 15,

and 16 (restoring

deep defects). (c and

d) Further esthetic

improvement was

realized by surgical

root coverage of the

cervical lesions

(combination of CTG

and CAF) on teeth 13,

14, 15, 16, 21, 23, and

26. (e) Final result

after surgical root

coverage of the

cervical lesions

(combination of CTG

and CAF) on teeth 13,

14, 15, and 16.

a

b c

d

e

CLINICAL RESEARCH


should be applied, with the appropriate ap-

proach adopted for the specific situation.

Particular attention should be paid to the

preventive phase, as this will also determine

the longevity of the restorative treatment.

When function and esthetics are impaired,

direct composite restorations are indicated

to restore deep lesions. These restorations

show an acceptable clinical performance in

the long term provided an adhesive system

with a good proven clinical performance is

selected. In addition, a high level of oper-

ator skill combined with a careful operative

procedure is required to enhance the lon-

gevity of the restorations.

In case NCCLs are associated with gingi-

val recession, the original soft and hard tis-

sue relation and structure can be restored

esthetically and functionally by a combined

perio-restorative intervention.

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Treatment of noncarious cervical lesions: when, why, and how

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