Class V restorations. A non-surgical simplified approach to improve the gingiva level

A clinical case by our Community member Dr Edoardo Fossati

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

Non carious cervical lesions (NCCL) are defined as the loss of dental substance located in the cervical third of the teeth. The etiology is rarely correlated with bacteria, while it’s usually due to a combination of factors, among which abrasion, erosion and abfraction [1]. Abrasion is usually caused by aggressive toothbrushing, erosion by the abnormal intake of very acid foods and drinks, and abfraction by the severe mechanical loading of the cervical third caused by daily and nightly clenching [2]. NCCLs are more common in the anterior area because the toothbrushing here is easier and because the patient pays more attention to the visible aesthetic region than to the posterior zone when it comes to toothbrushing [3,4]. Furthermore acid foods and drinks come into closer contact with the buccal areas than the palatal ones. It results in loss of the enamel and part of the dentin, sometimes reaching the pulp, with sensitivity and aesthetic problems [2].

The restoration of this kind of lesions is a challenge mainly because of the difficulties in placing the rubber dam, and because the patients often do not change their bad habits so that our restorations will be affected by several mechanical and chemical forces. Overall we should not forget that NCCLs are often combined with gingival recession that should be treated with periodontal surgery. However, it is really common for patients to decline a surgical treatment option, making it necessary to find a non-surgical treatment to reconstruct the tooth substance loss, the sensitivity and reduce much recession as possible. A different approach based on the Biologically Oriented Preparation Technique (BOPT) [5] protocol is here proposed and explained.

styleitaliano style italiano multiple cervical lesions

Fig.1
Initial situation. NCCL at teeth 13, 14, 15, 16. Patient complained about sensitivity.

styleitaliano style italiano class V cavities

Fig.2
This view highlights the depth of the lesions.

styleitaliano style italiano rotary gingival curettage with bur

Fig.3
Insertion of the bur (Komet 6658 314 012) in the sulcus to flatten the surface of the teeth and to perform a gingival rotary curettage.

styleitaliano style italiano isolation of cervical cavity

Fig.4
A 212 clamp is the best option when it comes to isolating NCCLs, especially when treating anterior teeth or premolars. The clam should be pretty new and its end sharpened to isolate the tooth really close to the gums. After placing the dental dam, my personal approach is to sandblast the surface of the dentin with the Al2O3 for 2-3 seconds to clean the tooth and to create a roughened surface to improve the adhesion [6].

styleitaliano style italiano etching cervical cavity

Fig.5
Etching using 37% orthophosphoric etching gel selectively on the enamel for 20s.

styleitaliano style italiano bonding class V cavity

Fig.6
Bonding using a universal adhesive (iBOND Universal) on the enamel and dentin (gently rubbed in for 20 seconds) and light-cured for 10s each tooth after carefully air-drying with a gentle oil-free air flow [7].

styleitaliano style italiano layering class V restoration

Fig.7
Application and curing of a 0.5 mm layer of a flowable composite (Venus Diamond Flow A 3.5). Then application and curing of a one shade composite (Venus Pearl ONE) in layers, working from coronal to apical.

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
styleitaliano style italiano layering composite for class V restoration

Fig.8
Working with multiple layers on cervical lesions is highly advisable, especially due to the material’s shrinkage and the mainly (or completely) dentine substrate.

styleitaliano style italiano raw class V restoration

Fig.9
The completed restoration, before finishing.

styleitaliano style italiano isolation and restoration of class V restoration on upper molar

Fig.10
The same workflow was repeated for the other teeth, from 14 to 16. A 27N clamp was used to isolate the molar.

styleitaliano style italiano finishing class V restorations

Fig.11
After completing the restorations, finishing was carried out using a diamond bur (Komet 6658 314 012).

styleitaliano style italiano polishing cervical restorations

Fig.12
Polishing of the restoration was completed using the two-step polishing system Venus Supra with water cooling.

styleitaliano style italiano polishing cervical restorations

Fig.13
Final polishing step.

styleitaliano style italiano finished class V restorations

Fig.14
The polished restorations, the gums will be healing in a few days.

styleitaliano style italiano healed gums near class V restorations

Fig.15
The final situation after one week.

styleitaliano style italiano creeping gums after class V restorations

Fig.16
The situation after ten weeks.

styleitaliano style italiano healed gums after class V restorations

Fig.17
Note the creeping of the gums upon healing.

styleitaliano style italiano creeping gums comparison before after class V restorations

Fig.18
Creeping of the gums before and 10 weeks after treatment.

Conclusions

Although most NCCLs would require a combined restorative and periodontal approach, patients usually ask to avoid surgery, leaving restorative coverage as the only treatment. Coverage of the root helps to lower the sensitivity associated with NCCLs, while creating a sort of protection of the gums towards heavy brushing if the emergence profile and buccal thickness are managed properly.

The key points to success in the restorative treatment of NCCLs are:

  • Removal of the line under the NCCL and the gingitage before the placement of the rubber dam. It’s impossibile to do this step at the end of the restorative process because the convexity of the restoration stops the insertion of the bur under the gum.
  • Isolation, meaning choosing a quite new and sharpened clamp
  • Even though evidence for intraoral air abrasion to improve bond strength to dentin and enamel is still debated, it is clear that sandblasting cleans and smoothens tooth surfaces. So my personal approach for the NCCL includes the intraoral air abrasion of the dentin before adhesion [6]
  • The layering technique from coronal to apical, using several layers and starting with a first flowable layer
  • Last but not least, the motivation of the patient to change his habits to reduce mechanical and chemical stress over the cervical restorations and the gums

Bibliography

  1. Goodacre C J, Roberts W E, Munoz C A. Noncarious cervical lesions: Morphology and progression, prevalence, etiology, pathophysiology, and clinical guidelines for restoration. J Prosthodont 2023;32:e1-e18.
  2. Soares P.V, Grippo J.O. Non carious cervical lesions and cervical dentin hypersensitivity. Quintessence publishing 2017
  3. Haralur SB, Alqahtani AS, AlMazni MS et Al. Association of Non-Carious Cervical Lesions with Oral Hygiene Habits and Dynamic Occlusal Parameters. Diagnostics 2019; 9(2):43
  4. Duangthip D, Man A, Hong Poon P, Chin Man Lo E et Al. Occlusal stress is involved in the formation of non-carious cervical lesions. A systematic review of abfraction. Am J Dent 2017; 30(4): 212-220
  5. Loi I, Di Felice A. Biologically oriented preparation technique (BOPT): a new approach for prosthetic restoration of periodontically healthy teeth. Eur J Esthet Dent. 2013; 8(1): 10-23
  6. Huang CT, Kim J, Arce C et Al. Intraoral air abrasion: a review of devices, materials, evidence, and clinical application in restorative dentistry. Compend Contin Educ Dent 2019; 40:508-13.
  7. The influence of selective enamel etch and self-etch mode of universal adhesives’ application on clinical behavior of composite restorations placed on non-carious cervical lesions: A systematic review and meta-analysis. Dent Mater 2022; 38(3): 472-488.

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