An Alternative for Treating Abfractions
Chad J. Anderson, DMD, MS
Treatment of a noncarious erosive lesion in the esthetic zone with a gingiva-colored composite resin.
Restorative material selection for treating the noncarious erosive cervical lesion that will best achieve the long-term objective of the patient is quite limited. Glass-ionomer cements and compomers have been used, and glass ionomers are considered by some to be the best long-term restorative choice.1 However, glass ionomers will not address the patient's chief complaint of providing an esthetically pleasing result. Currently, only composite resins and porcelains are available in gingival colors. In the clinical case presented in this article, a porcelain restoration was considered but rejected by the patient because of financial considerations. It was determined that Amaris® (VOCO America, Inc, https://www.vocoamerica.com) gingiva-colored composite resin would be used to achieve coverage of the root surface and give the patient the desired esthetic outcome she wanted.
Case Presentation
A 52-year-old female patient of record presented with a long-standing, significant gingival defect located on her upper left cuspid, tooth No. 11 (Figure 1 ). The defect was 5 mm in length, and extended from the cemento-enamel junction to just short of the depth of the buccal vestibule. The patient was concerned about the unattractive esthetics of "the dark root showing." The patient had been referred to a periodontist for consultation to have a gingival graft placed over the exposed root area but the patient declined treatment multiple times. The patient had concerns over finances and the possibility of not achieving complete coverage of the exposed root after the periodontal grafting procedure.
Although the patient did not have a high smile line, she was conscious of the receding gum tissue. A clinical examination revealed a muco-gingival defect and lack of attached gingival tissue. The exposed root surface showed no signs of carious lesions and was described as a Class V non-carious cervical lesion.
The literature suggests that these lesions are primarily due to occlusal stress that produces cervical cracks and makes the cemento-enamel junction susceptible to erosion and abrasion.2 In this patient's case, a fractured Maryland bridge replacing congenitally missing lateral incisors could account for an increased occlusal load. The patient was compliant with her oral hygiene protocol and exhibited mild plaque accumulations. It is described in the literature that overly aggressive plaque control can contribute to these class V non-carious lesions (abfractions).3
Treatment
The first step was to select the proper color for the restoration (Figure 2 ). Amaris Gingiva uses a combination of base shade (nature), which is the filled bulk composite resin (similar to an enamel shade, translucent composite) with three mixable opaque shades. These opaque shades can be laid down into a thin, flowable composite base to block out any underlying colors. The opaques come in dark, light, and white (Figure 3 and Figure 4 ). Figure 3 shows the nature composite overlaying each opaque base from left to right: nature, dark, light, and white (Figure 5 ). Color selection is important before anesthetic is given because epinephrine, which is in most anesthetics, will cause vasoconstriction and initiate gingival blanching and change the color of the gingival tissues.4 Bonding agents and retraction cord as well as mechanical abrasion may induce bleeding and can affect color selection.5
After infiltration with anesthetic containing epinephrine 1:200,000 (Septocaine®, Septodont, https://www.septodont.com) a KS0 diamond bur (Brasseler USA, https://www.brasselerusa.com) was used to ensure removal of any sclerotic dentin and to improve the application and penetration of the bonding agent (Figure 6 ). Futurabond DC (VOCO America Inc) was chosen for its self-etching ease of use and compatibility with the Amaris Gingiva composite resin (Figure 7 ). The Futurebond DC was scrubbed into the surface of the root exposure for 20 seconds, air-dried for 5 seconds, and then light-cured for 10 seconds (Figure 8 ).
Because of the depth of the abfraction and thick adjacent gingival margins, no opaquer was used; adequate thickness of the composite was achieved to block out the underlying root discoloration. Two layers of the Amaris Gingiva shade "nature" composite were placed. The first layer of composite, 1.5 mm thick, was placed and cured for 20 seconds. It was determined that a second layer was necessary to overfill all of the voids and provide for excess composite to ensure that no oxygen-inhibited resin and unpolymerized composite would be present after shaping and polishing. The second layer was cured for 20 seconds. This step of overfilling and reducing is critical for long-term color stability. It is possible to use an oxygen-inhibiting material such as KY® jelly (Johnson and Johnson, https://www.jnj.com), DeOx® (Ultradent Products, Inc, https://www.ultradent.com) or another appropriate water-based glycerin lubricant, but this filled-to-ideal technique allows little room for error during the color-matching and finishing process.
The restoration was then contoured flush with the gingival margin with a fine flame-shaped diamond NTI135014 (Axis Dental Corp, https://www.axisdental.com) and 135F (Brasseler USA) (Figure 9 ). This bur can be used to define line angles and give initial surface texture to reveal the hue and translucency of the restoration, as well as remove the bulk excess of composite and feather seamlessly into the existing tooth structure or restorative material.
This step was followed by the use of a medium-coarse OptiDisc® (Kerr Corporation, https://www.kerrdental.com) for finer shaping and to close the composites' grain in preparation for the polishing phase. A HiLuster Plus polisher (Kerr Corporation) was used to finish, followed by an Occlubrush™ (Kerr Corporation). A Jiffy® brush (Ultradent Products) could also be used in this step. The Occlubrush is an intermediate-stage polisher that is not used to shape but provides a luster that scatters light and provides a natural optical property as well as reduces plaque accumulations (Figure 10 ). Figure 11 and Figure 12 show the restoration immediately after polishing.
The patient was recalled 3 days postoperatively for follow-up. She was very satisfied with the treatment, and she was especially happy with how her gingival tissue appeared when smiling (Figure 13 ).
Conclusion
Noncarious cervical lesions or abfractions have typically been treated with tooth-colored composite restorations. These tooth-colored or white restorations can have an unpleasant appearance in the esthetic zone. With the advent of gingiva-colored composites, the practitioner now has an alternative material option for treating these lesions. With proper case selection and treatment planning, an esthetically acceptable result can be achieved.
References
1. Bracket WW. Two-year clinical performance of a polyacid-modified resin composite and a resin-modified glass-ionomer restorative material. Oper Dent. 2001;26(1):12-16.
2. Bartlett DW, Shah P. A critical review of non-carious cervical (wear) lesions and the role of abfraction, erosion and abrasion. J Dent Res. 2006;85(4):306-312.
3. Abrahamsen TC. The worn dentition-pathognomonic patterns of abrasion and erosion. Int Dent J. 2005;55(4 Suppl 1):268-276.
4. Sadove MS, Kolodny S. Local anesthetic agents in combination with vasoconstrictors. Part I: Epinephrine. Acta Anaesthesiologica Scandinavica. 1961;5:13-19.
5. Fazekas A. Effects of pre-soaked retraction cords on the microcirculation of the human gingival margin. Oper Dent. 2002;27(4):343-348.
Chad J. Anderson, DMD, MS
Research Instructor
Tufts University School of Dental Medicine
Boston, Massachusetts
Private Practice
Fresno, California
