Tooth Surface Lesions Part II
Prevention and Treatment
Douglas A. Terry, DDS
**NOTE** Part I of this article can be found here: http://thenextdds.com/Articles/Tooth-Surface-Lesions-Part-I/
The operative requirements for the restoration of carious
and noncarious tooth surface lesions have been the creation of gingival health
through developing proper anatomical contours, marginal integrity, and surface
texture. In the past, restorative therapy of the lesion was limited to
artificial replacement of the tooth structure by operative procedures. The
restorative material selection and operative techniques were designed to follow
the concept of “form and function.”
Today, an expanded philosophy has developed with an improved
scientific knowledge of these lesions and the addition of a third element, aesthetics,
to the restorative equation. This new philosophy requires an interdisciplinary approach
for reconstruction of the dentogingival complex. The new parameters of
restorative therapy require a “true aesthetic consideration” for the treatment
of tooth surface lesions, which may require periodontal and/or operative dental
procedures to restore harmony and aesthetic balance.
Management and Prevention
The management of surface lesions begins with diagnosing the
etiology and prevention. The modern management and prevention of surface
lesions should aim to prevent initial restorative therapy, preserve hard- and
soft-tissue structure, and increase the longevity of the restorative therapy.1
Controlling and preventing the advancement of hard-tissue destruction begins
with dietary instructions, fluoride therapy, brushing with desensitizing
dentrifices, and improved oral habits. Management of these lesions may include
remineralization through the in-office application of fluorides, calcium, and
potassium phosphate. Desensitization of these hard surface lesions can be achieved
through the professional application of potassium oxalate or other
tubule-occluding agents, iontophoresis, or application of dentin adhesives.
Other management methods include occlusal evaluation and equilibration with
occlusal guard fabrication, coronoplasty, or orthodontic treatment.2-4
Defining Restorative Therapy
Reconstruction of these cervical lesions may require an
interdisciplinary diagnosis and treatment planning. Treatment may involve
periodontal surgery, orthodontic measures, and operative procedures. Periodontal
procedures include free autogenous mucosal grafts, subepithelial connective
tissue grafts, coronally advanced flap technique, guided tissue regeneration,
and enamel matrix derivative grafts.5 Operative methods can involve
the use of glass ionomers, compomers, composite resins, or various laboratory-fabricated
restorations.4 Orthodontic therapy can involve intrusion,
uprighting, space closure, and restoration of occlusion.6
After the diagnostic and preventive phase, the concern
focuses on the direction of the restorative treatment. Treatment depends on the
location and the size of the lesion,4 its relationship to the
cementoenamel junction (CEJ), and the amount of gingival recession. In 1985, in
order to identify and categorize gingival recession in relationship to the
amount of root coverage anticipated, Miller described four categories for
recession-type defects (Table 1).7 A periodontal approach should be
considered when there is root exposure, when the lesion is apical to the CEJ,
and when it is possible to remove the caries or existing restoration and
achieve a relatively flat root surface without endangering the pulp. The
carious lesion or recurrent decay on an existing restoration coronal to the CEJ
should be removed and restored before surgical treatment. Restorations below
the CEJ should be removed prior to surgery because the presence of restorative
materials on the root surface precludes the ability to perform root coverage
procedures.8 In addition, an operative-only approach should be
considered if the lesion is coronal to the CEJ in the absence of gingival
recession (Figure 1).
Surgical Treatment of
Recession-Type Lesions
Periodontal surgical procedures should be part of the
clinician’s technique for restoring the dentogingival complex. Traditionally,
restorative therapy of teeth with gingival recession and carious or noncarious
lesions has been achieved through operative procedures with little attention to
aesthetics. In contrast, the perio-aesthetic approach considers the harmonious
integration and interrelationship of the hard and soft tissue (Figures 2 and 3),
and there are numerous mucogingival procedures available for the
treatment of gingival recession-type lesions (eg, free gingival autografts,
subepithelial connective tissue grafts, coronally positioned flaps).5
These soft-tissue grafts are indicated for the restoration of cervical
radicular lesions and for previously restored Class V restorations associated
with gingival recession.
Operative Treatment of Tooth
Surface Cervical Lesions
Many restorative alternatives, such as direct resins and
indirect inlays, exist for the replacement of tooth structure lesions.2,9
The initial consideration for the selection of a direct restorative material is
to determine the type of cervical lesion and whether it is carious or noncarious.
The choice of restorative materials for the carious lesion could require a
fluoride-releasing material (eg, modified glass ionomers or compomers). When
fluoride is not a consideration, however, composite resin provides an optimal
aesthetic result for the carious and noncarious cervical lesion, because of the
acid-etch technique and the chemical attachment to tooth structure through
dentinal bonding systems.4 Hybrids, microfills, and flowable
composites are among the options for use in cervical lesions. Investigations
from Heymann et al on occlusal factors that influence the retention of
restorations and the tooth flexure theory indicate that forces are transmitted
through the cusp and concentrated in the cervical region of the tooth.10
Such data influences the type of restorative material that is selected for
cervical lesions. Composite resins with a low modulus of elasticity will absorb
this transferred energy from the occlusal surface, preventing transmission to
the dentin-restorative interface. These low modulus resins have a lower level
of filler loading, and there is a difference in the values between filler
particles and the resin matrix.6 The microfill and flowable
composite resins have a lower modulus of elasticity than hybrid or conventional
composite resin.4 Additionally, dentin bonding systems provide an
elastic intermediate layer between the restorative material and the
cavosurface, to absorb this flexural deformation of the tooth.
A successful operative procedure with the utilization of
composite resins for lesions relies on the type of selected material, cavity
design, isolation, and occlusion. Fundamental principles of this process
require maintaining sound tooth structure, achieving a sterile, gap-free hybrid
layer, and eliminating microleakage.11
Conclusion
Changes in the understanding of the etiology of cervical lesions
have attributed to the methods in which they are treated. The adoption of a
modern philosophy of “medical management” has rendered diagnosis, prevention,
and treatment planning essential components of comprehensive treatment. Thus,
contemporary restorative concepts have evolved to redefine restorative
treatment to include surgical and operative procedures in the treatment of these
tooth surface lesions. Therefore, restorative therapy becomes a process of all
disciplines instead of a term used for the definitive prosthetic and/or
operative therapy.
*Assistant
Professor, Department of Restorative Dentistry and Biomaterials, University of
Texas Health Science Center Dental Branch, Houston, TX; private practice,
Houston, TX.
References
- Mount GJ,
Hume WR. A new cavity classification. Aust Dent J 1998;43(3):153-159
- Grippo JO. Noncarious cervical lesions: The decision to ignore or restore. J
Esthet Dent 1992;4 Suppl:55-64.
- Eccles JD. Tooth surface loss from abrasion, attrition, and erosion. Dent Update 1982:9(7):373-381.
- Lambrechts P, Van Meerbeek B , Perdigão J, et al. Restorative therapy for
erosive lesions. Eur J Oral Sci
1996;104(2):229-240.
- Camargo PM, Lagos RA, Lekovic V, Wolinsky LE. Soft tissue root coverage as
treatment for cervical abrasion and caries. Gen Dent 2001;49(3):299-304.
- Bednar JR, Wise RJ. Interaction of periodontal and orthodontic treatment. In:
Nevins M, Mellonig JT, eds. Periodontal
Therapy: Clinical Approaches and Evidence of Success. Carol Stream, IL:
Quintessence Publishing; 1998:149-164.
- Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent
1985;5(2):8-13.
- Pini Prato G, Tinti C, Cortellini P, et al. Periodontal regenerative therapy
with coverage of previously restored root surfaces: Case reports. Int J Periodontics Restorative Dent
1992;12:451-461.
- Miller MB. Restoring Class V lesion Part 1: Carious lesions. Pract Periodontics
Aesthet Dent 1997;9(4): 441-442.
- Heymann HO, Sturdevant JR, Bayne SC, et al. Examining tooth flexure effects on
cervical restorations: a two-year clinical study. J Am Dent Assoc 1991;122(5):41-7.
- Terry, DA. Natural Aesthetics with Composite Resin; 1st ed, Montage
Media Publishing 2004; Mahwah
NJ, USA.
Tables
Table 1: Miller’s Classification of Recession-Type Defects
Class
I | Marginal
recession that does not extend to the mucogingival junction. Complete root
coverage can be achieved. |
Class
II | Marginal
recession that extends to or beyond the mucogingival junction, with no
periodontal attachment loss (ie, bone or soft tissue) in the interdental area.
Complete root coverage can be achieved |
Class
III | Marginal
recession that extends to, or beyond, the mucogingival junction, with
periodontal attachment loss in the interdental area or malpositioning of the
teeth. Only partial root coverage can be achieved to the height of the
contour of the interproximal tissue. |
Class
IV | Marginal
recession that extends to or beyond the mucogingival junction, with severe
bone or soft-tissue loss in the interdental area and/or severe malpositioning
of the teeth. Root coverage is unpredictable and requires adjunctive (ie,
orthodontic) treatment. |