Volume 77 Number 4

Innovations in Periodontics
Clinical and Anatomical Factors Limiting Treatment
Outcomes of Gingival Recession: A New Method to
Predetermine the Line of Root Coverage
G. Zucchelli,* T. Testori, and M. De Sanctis

Complete root coverage is not always achievable,

even in gingival recession with no loss of interproximal attachment and bone. The cemento-enamel junction is the most widely used referring parameter to
evaluate root coverage results. The aim of the present
study was to describe the most frequent diagnostic
mistakes that may lead to incomplete root coverage
in Miller Class I and II gingival recessions and to suggest a method to predetermine the level/line of root
coverage in non-molar teeth.
The line of root coverage (i.e., the level/line to
which the soft tissue margin will be positioned after
the healing process of a root coverage surgical technique) was predetermined by calculating the ideal
vertical dimension of the interdental papilla of the
tooth with the recession defect. This method was applied to 120 recession-type defects affecting nonmolar teeth of 80 young healthy subjects that were
treated with root coverage surgical procedures over
the last 5 years. All recessions were Miller Class I
or II and were associated with at least one of the following characteristics: 1) traumatic loss of the tip of
the interdental papilla(e); 2) tooth rotation; 3) tooth
extrusion with or without occlusal abrasion; and 4)
a cervical abrasion defect with no evidence of the
cemento-enamel junction.
The line of root coverage may be considered the
clinical cemento-enamel junction because it may
substitute the anatomic cemento-enamel junction
when this is no longer clinically visible on the tooth
with recession or when the ideal conditions to obtain
complete root coverage are not fully represented.
J Periodontol 2006;77:714-721.
KEY WORDS
Cemento-enamel junction; gingival recession;
interdental papilla; surgery.

* Department of Odontostomatology, Bologna University, Bologna, Italy.

Department of Periodontology and Implantology, Milan University, Milan,
Italy.
Department of Periodontology, Siena University, Siena, Italy.

714

he gingival margin is clinically represented by

a scalloped line that follows the outline of the
cemento-enamel junction (CEJ), 1 to 2 mm
coronal to it.1 Gingival recession is an apical shift of
gingival margin with exposure of the root surface to
the oral cavity.1 Gingival recession may involve one
or more tooth surfaces. The objective of mucogingival surgery is the treatment of the recession limited
to one surface (generally the buccal one) with no
associated severe attachment loss at the interproximal surfaces.
In the literature, gingival recessions have been
classified into four classes, according to the prognosis of root coverage.2 In Class I and II gingival
recessions, there is no loss of interproximal periodontal attachment, and bone and complete root
coverage can be achieved; in Class III, the loss of
interdental periodontal support is mild to moderate,
and partial root coverage can be accomplished; in
Class IV, the loss of interproximal periodontal attachment is so severe that no root coverage is
feasible.
In the recent literature,3,4 the root coverage predictability of a mucogingival surgical procedure is
measured in terms of the percentage of root coverage (indicating the percentage of the root exposure
that is covered with soft tissues after the healing
period) and the percentage of complete root surface
(showing in which percentage of the treated cases
the soft tissue margin has been repositioned at the
level of the CEJ). For the correct evaluation of both
these parameters, it is necessary to recognize the
CEJ, which anatomically separates the crown from
the root, on the tooth with the recession defect.
Therefore, the clinical healing pattern of only those
gingival recessions in which the CEJ is clinically
detectable could be evaluated in terms of percentage
and/or complete root coverage. When the CEJ is not
recognizable, it is no longer possible to measure the
depth (and width) of the recession or to assess the

doi: 10.1902/jop.2006.050038

Zucchelli, Testori, De Sanctis

J Periodontol April 2006

efficacy of a surgical technique in terms of root

coverage, due to the lack of the referring parameter.
The international literature has thoroughly documented that gingival recession can be successfully
treated by several surgical procedures,1,3 irrespective of the technique used, provided that the following biologic conditions for accomplishing root
coverage are satisfied: no loss of interdental soft and
hard tissue height.2
However, some surgical approaches have been
reported to be more predictable compared to others
in terms of root coverage:3,4 these are the coronally
advanced flap (CAF) and the bilaminar techniques.5
Even for these procedures, a great variability of
clinical outcomes does exist, and data expressed in
terms of complete root coverage are always quite far
from the desired 100%.3,4 It could be argued that
some presumed failures (or incomplete successes)
in terms of root coverage could be ascribed to
mistakes in the selection of the clinical case or of the
referring measurement parameters rather than to the
inefficacy of the surgical technique.
The aim of the present study was to identify some
of the most frequent diagnostic mistakes leading
to incomplete root coverage in Miller2 Class I and II
gingival recessions and to suggest a method to
predetermine the position of the soft tissue margin
after a mucogingival surgical procedure.
Mistakes in Selection of Reference
Measurement Parameters
The most frequent mistake in the selection of the
reference parameters concerns the localization of the
anatomic CEJ on the tooth with the recession defect.
In a recent analysis (our unpublished data) on 900
teeth with gingival recession (360 patients), the CEJ
was completely detectable in 30% and partially
recognizable in 25% of the selected cases. Therefore,
there was no sign left of the anatomic CEJ in about
half of the examined teeth. In the great majority
(>90%) of these teeth, cervical abrasions were
associated with the recession of the soft tissue
margin. It can be speculated that the etiologic factor,
likely traumatic (toothbrushing trauma), may have
occurred at the cervical region of the tooth, provoking gingival recession initially and tooth abrasion
afterwards. It is highly improbable that the abrasive
trauma was limited to the area of the exposed root.
More probably, the abrasive trauma involved the
whole cervical area and, thus, both the enamel and
the root cementum, causing the disappearance of
the anatomic line (CEJ) which separated the crown
from the root. In many cases of gingival recessions
associated with cervical abrasion, a line separating
the enamel from the coronal dentin (exposed due to
the abrasion defect) does appear, and this is fre-

quently confused with the anatomic CEJ (Fig. 1A).

This error in the localization of the CEJ leads to other
measurement mistakes, obviously making the desired root coverage unobtainable. In fact, the patient
hopes for a complete coverage of the exposed
dentin, but this result is not achievable because the
most coronal portion of the exposed dentin belongs
to the anatomic tooth crown, and thus it is not
coverable with the soft tissues. Post-surgical dentin
exposure may be erroneously considered a failure
(or incomplete success) of the root coverage surgical technique (Fig. 1B).
To avoid this mistake, the clinician must carefully
observe the outline of the line he/she considers to be
the anatomic CEJ. In fact, this line has a curved,
convex outline, more or less scalloped, according to
the patients biotype. On the contrary, in the great
majority of cases, the abrasion lines are flat.
The differential diagnosis between abrasion line
and anatomic CEJ is often more difficult in posterior
teeth (premolar and molar), which are characterized
by a flatter outline of the CEJ even in a thin and
scalloped patients biotype. Nevertheless, a careful
observation (better with magnification lenses) will
allow the clinician to distinguish the straight (sometimes concave) outline of the abrasion line from the
more scalloped and convex outline of the anatomic
CEJ.
Mistakes in the Selection of the Clinical Case
The following local conditions at the tooth with the
recession defect may limit root coverage even in the

Figure 1.
A) A canine with deep gingival recession and shallow root abrasion.
A line (arrow) can be hardly recognized separating the enamel from
the coronally exposed dentin. This line is too flat to be considered the
anatomic CEJ, which has disappeared due to the abrasion defect. B)
After the root coverage surgical procedure, the abrasion line (arrow)
is more evident than before the surgery due to chlorhexidine
pigmentation of the exposed (non-coverable) coronal dentin. The
patient may consider the end result as a failure of the surgical
procedure which, conversely, achieved good root coverage.
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absence of interdental attachment and bone loss: 1) loss

of the interdental papilla(e)
height; 2) tooth rotation; 3)
tooth extrusion; and 4) occlusal
abrasion. If the clinician does
not recognize these situations
as factors impairing complete
root coverage, the persistence
of root exposure after surgery
could be erroneously considered a failure of the root coverage surgical procedure.
Figure 2.
Loss of interdental papilla(e)
Clinical CEJ predetermination in a tooth with reduction of the height of both papillae (a canine with a
height (Figs. 2 and 3). In
deep gingival recession and shallow root abrasion). There is no loss of interdental periodontal
subjects with thin and highly
attachment and bone. The anatomic papillae do not completely fill the interdental space up to the
contact point due to a traumatic loss of their tips. A) The ideal height (x) of the interdental papilla is
scalloped biotype, the intermeasured as the distance between the projection (gray line) of the mesial line angle and the contact
dental papillae are long, thin,
point. B) The ideal dimension (x) is reported apically starting from the tip of both mesial and distal
and triangular-shaped with
anatomic papillae. Projections (gray lines) on the recession margin of these measurements permit the
sharp tips. In a healthy peridiscovery of two points (green dots) that are connected by the line of root coverage (red line), i.e., the
odontium of non-molar teeth,
clinical CEJ. C) The red line represents the most coronal level of the root exposure that is coverable
(screened area) with soft tissues after a root coverage surgical procedure. D) Clinical healing 2 months
the papillae fill the interdental
after the root coverage surgical procedure. The most coronal portion of the root is already
space up to the contact point
exposed despite being covered with soft tissue at the end of the surgery. The amount of root coverage
6-8
between adjacent teeth.
was well matched with the amount that was predetermined before the surgery.
This long papilla, and particularly the tip of it, is very
other side, it gets farther. The situation in which
delicate because it is histologically characterized by
the CEJ gets closer to the tip of anatomic papilla
a keratinized epithelium supported by a thin and thus
configures a condition of a loss of papilla height
poorly vascularized connective tissue. Improper use
clinically similar to that caused by trauma. The only
(by the patient or by the dental hygienist) of hygienic
difference between these situations is that one or
interdental tools may traumatize the tip of this
both of the interdental papillae can be involved in the
papilla, thereby causing recession. Loss of the
case of traumatic loss, whereas in the case of tooth
papilla height can also be caused by inflammatory
rotation, the height of only one papilla is reduced.
periodontal disease due to bacterial plaque (gingiviRoot coverage surgical techniques will leave a
tis). In cases of trauma and gingivitis, there is no loss
portion of root surface uncovered at the tooth side
of interdental periodontal attachment and bone.
where there is reduction of papilla height; this is often
During mucogingival surgery, the interdental paerroneously considered a failure of the root coverage
pillae (once disepithelized) act as the most coronal
procedure.
vascular beds to which the soft tissues covering the
Tooth extrusion (Fig. 5). Loss of an antagonist
root exposure are anchored (sutured).9-12 A loss of
tooth or more complex occlusal disorders may
papilla height will decrease the potential advanceinduce extrusion of a single tooth with no associated
ment of the coronal flap and reduce the vascular
extrusion of supporting interdental periodontal tisexchanges between the root covering soft tissues
sues. In an extruded tooth, the CEJ gets closer to the
and the interdental connective tissue.
tip of both interdental papillae, and thus a condition
Extrapolating from the Miller classification,2 a
of bilateral reduction of interdental papillae height is
tooth with gingival recession and with no loss of
created. In this case, too, it is not possible to cover
interdental attachment and bone requires a definite
gingival recession up to the anatomic CEJ, and the
papilla height so that complete root coverage can be
persistence of a root exposure (the depth of which
accomplished; if some papilla(e) is lost, coverage up
should correspond to the amount of tooth extrusion)
to the CEJ cannot be achieved.
must not be considered a failure of the root coverage
Tooth rotation (Fig. 4). In a rotated tooth, the
surgical procedure.
topographic relationship between the CEJ and the
Occlusal abrasion (Fig. 6). The specific type of
interdental papillae, mesial and distal to the tooth
occlusion/malocclusion or more complex parafuncwith recession, changes: at one tooth side (mesial or
tions may induce occlusal abrasion phenomena.
distal according to the sense of rotation), the CEJ
Occlusal abrasion is frequently associated with
gets closer to the tip of the papilla, whereas at the
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J Periodontol April 2006

Figure 3.
Clinical CEJ predetermination in a tooth with loss of height of one papilla. In a canine with a deep
gingival recession, there is a loss of the distal papilla, whereas the mesial papilla completely filled the
interdental space up to the contact point. A) The ideal dimension (x) of the interdental papilla is
measured as the distance between the projection (gray line) of the mesial line angle and the contact
point. This dimension coincides with the height of the mesial anatomic papilla. B) The ideal dimension
(x) is reported apically starting from the tip of both mesial and distal anatomic papillae. Projections
(gray lines) on the recession margin of these measurements permit the identification of two points
(green dots) that are connected by the line of root coverage (red line). Note that the mesial point
coincides with the mesial line angle of the tooth, whereas the distal point is displaced more apically than
the distal line angle. C) The coverable area (screened area) differs in the mesial aspect with respect to
the distal aspect of the exposed root. At the distal aspect of the buccal surface, it is not possible to
cover the exposed root up to the anatomic CEJ, whereas complete root coverage is achieved at the
mesial aspect. D) Clinical healing 2 months after the root coverage surgical procedure. The distal aspect
of the buccal root surface is already exposed. The clinical root coverage differs in the mesial and distal
aspects of the exposed root surface as predetermined before the surgery.

Figure 4.
Clinical CEJ predetermination in a rotated tooth. A) A rotated canine with gingival recession. The
anatomic CEJ is easily recognizable, and both mesial and distal papillae fill the interdental spaces up
to the contact point. Thus, there is no loss of papillae height. Nevertheless, due to tooth
rotation, the topographic relationship between the anatomic CEJ and the interdental papillae changes:
at the mesial aspect of the buccal surface, the CEJ moves closer to the tip of the papilla, whereas at the
distal aspect it moves further away. The situation in which the CEJ moves closer to the tip of anatomic
papilla configures a condition of loss of papilla height. B) In a rotated tooth, the contact points with
adjacent teeth are not correct, and thus the ideal vertical dimension of the papilla (x) cannot be
measured at the tooth with recession but is measured at the homologous contralateral canine. The
ideal dimension of the papilla is measured as the distance between the mesial line angle and the
contact point. C) This dimension (x) is reported apically starting from the tip of both the anatomic
papillae of the rotated tooth with gingival recession. Projections of these measurements (gray lines)
allow the identification of two points (green dots) along the recession margin that are connected
by the scalloped line of root coverage (red line). The coverable (with soft tissues) area (screened area)
is less than the root exposure. D) Clinical healing 2 months after the root coverage surgical procedure.
The mesial aspect of the buccal root surface is already exposed. The clinical root coverage differs in the
mesial and distal aspects of the exposed root surface as predetermined before the surgery. Note that
chlorhexidine pigmentation makes the portion of the root surface that is non-coverable with soft tissues
even more evident and unesthetic because of tooth rotation.

Zucchelli, Testori, De Sanctis

progressive tooth extrusion

(tooth eruption continues
until reaching the antagonist
tooth), which, by itself, configures a condition of bilateral
loss of interdental papillae. A
tooth with occlusal abrasion
is frequently extruded, and
thus, in the presence of gingival recession, it cannot be
completely covered with the
soft tissue up to the level of
the anatomic CEJ.
A METHOD TO PREDETERMINE THE LINE OF
ROOT COVERAGE
Due to the difficulty of identifying the anatomic CEJ at
the tooth with the recession
and the presence of anatomic or clinical conditions
that limit root coverage even
in Class I and II gingival
recessions,2 a method to
predetermine the line of root
coverage (i.e., the level/line
to which the soft tissue
margin will be stable after
the healing process of a root
coverage surgical procedure)
should be discovered. This
line should substitute the
anatomic CEJ when this is
not clinically detectable on
the tooth with recession or
when the ideal anatomic
conditions to obtain complete root coverage are not
fully present. Therefore, this
line should be considered
the clinical CEJ.
The height of anatomic
papilla can be measured as
the distance between the
line connecting the line angles of adjacent teeth and
the tip of the papilla.8,9 In a
healthy periodontium, at the
level of non-molar teeth and
in the absence of tooth rotation, the tip of the papilla
coincides with the contact
point with no space between
them. Based on Millers definition,2 it can been speculated
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Volume 77 Number 4

because the contact points

with adjacent teeth are not
correct (Fig. 4B).
Once the ideal papilla has
been measured, this dimension is reported apically
starting from the tip of both
papillae mesial and distal to
the tooth with the recession
defect. The projections on
the recession margin of these
Figure 5.
measurements allow identifiClinical CEJ predetermination in an extruded tooth. A) A first premolar with gingival recession. Loss
of the antagonist tooth makes the premolar extrude. In an extruded tooth, the anatomic CEJ gets closer
cation of two points that are
to the tip of both interdental papillae, and thus a condition of bilateral loss of interdental papillae height
connected by a scalloped line,
is configured. B) The measurement of the ideal papilla (x) is performed at the adjacent homologous
the outline of which varies
non-extruded tooth (second premolar). The dimension of ideal papilla (x) is reported apically from the
according to the patients biotip of both the anatomic papillae of the extruded tooth. The obtained line of root coverage (red line) is
types and the shape of the
parallel to the anatomic CEJ at a distance from it and equal to the amount of tooth extrusion. C) The
coverable portion of root exposure (screened area). D) Clinical healing 2 months after the root
anatomic CEJ of other adjacoverage surgical procedure. The most coronal portion of the root is already exposed. Note that the
cent teeth. This line represents
soft tissue margin is at the same level in the second premolar.
the line of root coverage or the
so-called clinical CEJ.
This method was applied to 120 recession-type
defects affecting non-molar teeth of 80 young
healthy subjects (49 females and 31 males; age
range: 18 to 40 years) who were treated with root
coverage surgical procedures during the last 5 years
at the departments of periodontology of Bologna and
Siena Universities and in three private practices
located in Bologna, Como, and Florence, Italy. All
recessions were Class I or II according to the
definitions given by Miller2 and were associated
with at least one of the following characteristics: 1)
traumatic loss of the tip of the interdental papilla(e);
2) tooth rotation; 3) tooth extrusion with or without
occlusal abrasion; and 4) cervical abrasion defect
Figure 6.
Occlusal abrasion and tooth extrusion. The length of the anatomic
with no evidence of the CEJ.
crowns (continuous lines) of the left upper incisors and cuspids is
much greater than that of the homologous contralateral teeth. The
extrusion of these latter teeth (note that the anatomic CEJs
positioned more coronally than the corresponding CEJs of the
homologous contralateral teeth) is not visible due to occlusal abrasion.
Root exposures affecting the extruded teeth cannot be covered with
gingival tissue even in the absence of a loss of interdental hard and
soft tissue height. (Dashed colored lines represent the clinical CEJs
of the teeth.)

that an ideal vertical dimension of the papilla does

exist that is able to support complete root coverage for every tooth with a recession defect, in the
absence of interdental attachment and bone loss. In
a non-rotated tooth, the ideal dimension of the
papilla is measured at the same tooth with gingival
recession as the distance between the mesial/
distal line angle and the contact point (Figs. 2A
and 3A), whereas the ideal papilla is measured at the
homologous contralateral tooth in a rotated tooth
718

Clinical CEJ Predetermination in a Tooth With

Loss of Interdental Papilla Height (Fig. 2)
In a tooth with traumatic loss of interdental papilla(e),
the height of the anatomic papilla(e) is obviously
lower than that of the ideal papilla, and the difference
is equal to the distance between the tip of the papilla
and the contact point. Once the ideal papilla has
been calculated (Fig. 2A), this dimension is reported
apically starting from the tip of both mesial and distal
anatomic papillae (Fig. 2B). Projections of these
measurements permit discovery of the two points on
the recession margin that are connected by the root
coverage line (Figs. 2B and 2C).
The loss of papilla height can involve one or both
interdental papillae neighboring the tooth with the
recession defect, and the vertical dimension of the
papillae can be reduced equally or differently in this
latter case. In the case of equal loss of papillae
height, the line of root coverage will reside apically

J Periodontol April 2006

and be parallel to the anatomic CEJ (Fig. 2D),

whereas the root coverage line will be displaced with
respect to the anatomic CEJ in the case of greater or
exclusive loss of one papilla (mesial or distal) (Fig. 3).
Clinical CEJ Predetermination in a
Rotated Tooth (Fig. 4)
In a rotated tooth, the contact points with adjacent
teeth are not correct. Thus, the ideal vertical dimension of the papilla cannot be measured at the tooth
with the recession, but it must be taken at the
homologous contralateral tooth (Fig. 4B). Once
this dimension is measured, it is reported apically
starting from the tip of both anatomic papillae of the
rotated tooth with gingival recession (Fig. 4C). The
projections of these measurements allow identification of two points along the recession margin that are
connected by the scalloped line of root coverage
(Fig. 4C).
Clinical CEJ Predetermination in an Extruded
Tooth (with or without occlusal abrasion) (Fig. 5)
The measurement of the ideal papilla is performed
at the adjacent homologous non-extruded tooth
(Fig. 5B) (in the case of premolar teeth) or at the
homologous contralateral tooth. As previously described for the other conditions, the dimension of the
ideal papilla is reported apically from the tip of both
anatomic papillae of the extruded tooth with the
recession defect (Fig. 5B). The obtained line of root
coverage will be parallel to the anatomic CEJ (if
recognizable) at a distance from it, which is equal to
the amount of tooth extrusion (Fig. 5C).
DISCUSSION
The predetermination of the line of root coverage
has different clinical applications, which may improve the final outcome of the mucogingival surgery, allow for a more esthetic treatment of cervical
abrasion associated with gingival recession, and
meet patient demands even when the local conditions are not favorable to accomplish a good esthetic result. Furthermore, the identification of the
clinical CEJ may permit a better evaluation of the
root coverage efficacy of a given surgical procedure when the referring anatomical parameters are
lacking or when the ideal conditions to achieve
complete root coverage are not fully satisfied (Miller
Class III).2
In a tooth in which the anatomic CEJ is no longer
discernible due to the presence of an abrasion defect, a line may become visible in the cervical area
(Fig. 1). This line, which appears due to the exposure
of coronal dentin (generally darker and more yellow
than the enamel), is frequently mistaken for the
anatomic CEJ. At the end of the surgery, the abra-

Zucchelli, Testori, De Sanctis

sion line is covered with soft tissues that have been

coronally advanced in excess to compensate the
post-surgical soft tissue shrinkage. During the first
healing period (15 to 30 days), the coronal dentin is
gradually exposed, and the abrasion area is often
more pigmented than before surgery because of the
post-surgical use of chlorhexidine therapy (Fig. 1B).
The patient often considers the reappearance of the
pigmented area as a surgical failure. Thus, it is very
important to speak to the patient before surgery,
clarifying that this post-surgical occurrence does not
depend on the faults and/or limits of the procedure
but is the consequence of specific clinical conditions
(i.e., cervical abrasions) originally present at the tooth
with the recession defect. Furthermore, the patient
has to be reassured that the pigmentation of the
exposed dentin is reversible with the use of simple
professional hygienic tools and procedures (polishing
with rubber cup and prophylaxis paste). It is important not to underestimate the clinicians ability to
predict and inform patients about the post-surgical
outcome, even if unfavorable. This ability increases
the patients trust and esteem in the clinician.
Whenever there is a probability that exposed
coronal dentin (not coverable with soft tissues)
may become an esthetic problem for the patient, it
is highly recommended to treat the abrasion area by
means of an esthetic restoration before surgical
treatment of gingival recession. In fact, the presence
of the exposed root surface apical to the abrasion
area facilitates the isolation of the operative field with
a rubber dam, and the identification of the line of root
coverage will provide the restorative dentist with a
guideline for the apical preparation of the composite
filling.
A situation similar to this may be verified when
there is a chromatic contrast between the anatomic
crown and root in the presence of a Class III gingival
recession.2 In this case, the periodontal treatment,
by itself, cannot satisfy the patients esthetic demands because it leaves the most coronal (and
darker) portion of exposed root surface uncovered.
In such a situation, the apical shift of the CEJ by
means of the composite restoration (made at the
level of the line of root coverage) and followed by
mucogingival treatment of the coverable portion of
the exposed root will allow the clinician to reach a
good esthetic result even when the anatomic/biologic conditions to obtain complete root coverage
are not fully represented.
In patients with gingival recessions due to toothbrushing trauma, cervical abrasions are frequently
associated with the root exposures. In many instances, the abrasion involves both the crown and
the exposed root causing the disappearance of the
anatomic CEJ (Fig. 7). In this case, restorative
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which move soft tissues coronally inside the abrasion

area, may hinder the patients plaque control and
may make a composite restoration with precise
marginal fit and correct emergency profile almost
unfeasible.
Root coverage predetermination facilitates conservative restorative treatment, and this will facilitate
the periodontal root coverage surgery in turn. The
clinical CEJ is used as a guideline for the apical
preparation of the composite, which can be stratified
and finished in an operative field adequately isolated
with a rubber dam. In turn, the composite filling
makes the mucogingival root coverage surgical
procedure much easier to perform by restoring the
tooth emergency profile and giving a stable, smooth,
and convex hard substrate for the coronal placement
of the flap.
These factors suggest that the combined restorative (before) and periodontal (after) treatment is
able to solve recession-abrasion defects better than
single restorative or mucogingival therapy alone
from esthetic and hygienic points of view.
Figure 7.
Combined restorative-periodontal treatment of cervical abrasion
associated with gingival recession. A) A canine tooth with gingival
recession and a deep abrasion defect. The anatomic CEJ has
disappeared. B) The clinical CEJ (red line) is located within the
deepest portion of the abrasion defect. The area of abrasion coronal
to the clinical CEJ was restored with composite (white area), whereas
the apical portion (screened area) of the abrasion defect together
with the root exposure was treated by means of root coverage
surgery. C) 1-year follow-up after composite restoration and root
coverage surgery (i.e., CAF). Note that the length of the clinical crown
has been reduced up to the predetermined location of the clinical CEJ.
D) Lateral view showing the depth of the abrasion defect. The
abrasion starts at the level of the tooth crown forming a step in the
enamel. E) The coronal step (in enamel) of the abrasion has been
reduced (coronal odontoplastic) with rotating burs and the clinical
crown of the tooth has been restored with composite restoration up
to the clinical CEJ. F) 1-year follow-up. A tooth emergency profile has
been obtained that is easy to clean by the patient and protects the
soft tissue margin.

treatment of the abrasion defect, by itself, cannot

solve the patients esthetic problem caused by the
excessive length of the tooth. In addition, when the
abrasion defect reaches the apical recession margin,
it is necessary to perform a surgical clinical crown
lengthening to expose radicular tissue apical to the
abrasion defect where precise preparation and
finishing of the composite restoration can be performed. The end result will be an even longer tooth
that is not satisfying for the patient.
On the other hand, mucogingival therapy is not
recommended by itself, particularly in the case of a
deep abrasion defect associated with gingival recession. In fact, root coverage surgical procedures,
720

CONCLUSIONS
Within the limits of the present study, the predetermination of the clinical CEJ might be used as
follows: 1) evaluating root coverage outcomes of a
given surgical procedure when the anatomic referring parameter (CEJ) is lacking; 2) improving
esthetic outcomes of gingival recessions; and 3)
combining restorative/periodontal treatment of a
cervical abrasion associated with gingival recession.
Clinical studies are needed to confirm and improve the validity of the presented method to predetermine the level/line of root coverage and to test its
clinical applications.
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Correspondence: Prof. Giovanni Zucchelli, Bologna University, Department of Odontostomatology, Via S. Vitale
59, 40125 Bologna, Italy. Fax: 39-05-1225208; e-mail:
zucchell@alma.unibo.it.
Accepted for publication September 26, 2005.

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