Treatment of Noncarious Cervical Lesions: When, Why, and How

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 Leuven, Kapucijnenvoer 33, Leuven, 3000, Belgium; Tel: +3216332744; Email: [email protected]

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

Abstract the lesions and how they compromise tooth vitality, function, and esthetics. Treatment options include Noncarious cervical lesions (NCCLs) involve the loss techniques to alleviate dentin hypersensitivity and the of hard tissue from the cervical areas of teeth through placement of an adhesive restoration, eventually in processes unrelated to caries. NCCLs are nowadays a combination with a root coverage surgical procedure. common pathology caused by changes in lifestyle An adhesive restoration is considered the last treat- and diet. The prevalence and severity of cervical wear ment option for NCCLs. increase with age. It is generally accepted that the le- Based on their excellent esthetic properties and good sions are not generated by a single factor but result clinical performance, there is a general indication to from a combination of factors. Among the factors place composite restorations for NCCLs. The clinical proposed to be related to the formation and progres- performance of these restorations is highly prod- sion of NCCLs are biocorrosion (erosion), friction uct-dependent, particularly regarding the adhesive (abrasion), and possibly occlusal stress (abfraction). system used. The type of composite material seems The clinical appearance of NCCLs can vary depending to have no signiﬁcant inﬂuence on the clinical perfor- on the type and severity of the etiologic factors in- mance of NCCL restorations in clinical trials. It is much volved. Practitioners should follow a checklist to more important that the operator carries out the clin- achieve an accurate diagnosis of the etiology of multi- ical procedure correctly. factorial NCCLs. Marginal degradation is frequently seen during aging. The successful prevention and management of NCCLs Yearly maintenance with the eventual repolishing of require an understanding of the etiology and risk fac- the restoration margins will lengthen the lifespan of tors, including how these change over time in individ- the restorations. ual patients. The decision to monitor NCCLs rather than intervene should be based on the progression of (Int J Esthet Dent 2020;15:16–42)

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 171717 CLINICAL RESEARCH

Introduction

NCCLs are the result of a pathological condition characterized by the loss of tooth structure at the cementoenamel junction (CEJ) that is unrelated to dental caries.1 The a 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 b based on current knowledge: prevention, monitoring, alleviation of dentin hypersensitivity, and treatment with an adhesive restoration.

Prevalence

The prevalence of NCCLs has been report- c 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 lesions caused by one precise etiologic factor. A general finding is that prevalence, se- d verity, and progression of NCCLs increase with age. This can be explained by extended Fig 1 Extracted teeth showing different forms of CCN Ls. (a) Cervical wear lesion exposure to etiologic factors, increased oc- on a mandibular central incisor mainly caused by erosion. Notice the poorly defined margins and adjacent smooth enamel surface. The lesion is most visible currence of gingival recession and bone at the buccal side but is also present at the proximal and lingual sides. (b) Very loss with more root surface exposure (which deep NCCL with sharply defined margins on a maxillary premolar caused by a raises the risk of cervical lesions), diminished combination of abfraction (wedge shaped) and abrasion (notice the horizontal quantity and quality of saliva, and composi- scratches in the depth of the lesion created by a toothbrush). The pulp is tional and microstructural changes of retracted and the dentin in the depth of the lesion is brown, discolored, and enamel and dentin.2,4,5 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, NCCLs are almost exclusively situated created by the bristles of a toothbrush, is slightly smoothened by erosion. on the facial surfaces of teeth; they seldom (d) Abfraction wedge-shaped lesion on retaining primary canine with sharp occur on the lingual surfaces and rarely on internal and external line angles and an apical extent relative to the CEJ. Notice the proximal ones. the severe occlusal wear facet, which suggests abnormal occlusal loading.

18 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 PEUMANS ET AL

Any tooth (incisor, canine, premolar or molar) may exhibit an NCCL.3,5 Several epidemiological studies have reported that premolars show the highest frequency of lesions.6-9 In some studies, the most commonly affected teeth were mandibular premolars,6,7 which also have the highest per- 7 centage of severe lesions. a

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. b ■ Disk-shaped broad and shallow lesions Fig 2 (a and b) Generalized tooth wear in a 21-year-old bruxing patient who with poorly defined margins and adja- drinks 3 liters of coca cola per day. Noncarious cervical active erosive lesions are cent smooth enamel margins are con- present on almost all of the buccal surfaces. The lesions are disk-shaped, broad, sidered to be the best predictive criteria and shallow, with poorly defined margins and adjacent smooth enamel areas. for the diagnosis of erosion as well as a Notice the defined enamel border at the gingival margins. All the teeth have pathognomonic sign of erosive tooth become shorter with time. The incisal/occlusal and palatal wear was caused by a wear (Fig 1a). In young patients with cer- combination of erosion and bruxism, which can be destructive for the dentition. All teeth showed hypersensitivity. 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 scratching (Figs 1b and 3). ■ Lesions caused by a combination of abrasion and erosion often have a U shape (Figs 1c and 4). ■ Lesions caused by abfraction due to ab- Fig 3 Cervical lesions on mandibular anterior incisors caused by an improper tooth brushing technique. These typical abrasive lesions exhibit sharply defined normal occlusal loading are typically margins and a hard surface with traces of scratching. The mandibular incisors do wedge shaped, with sharp internal and not make contact during habitual occlusion. Abfraction could have played a role external line angles, and an apical extent in the formation of the cervical wear lesions on the mandibular left canine and relative to the CEJ (Figs 1d and 5). first premolar.

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 19 CLINICAL RESEARCH

A common complaint of patients with erosive lesions is tooth hypersensitivity, an unavoidable problem if the corrosive challenge 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 action of two or three of the etiologic mech- Fig 4 NCCLs on teeth 32, 33, 34, and 36. The quite large lesions on teeth 33 anisms unique to that individual case: bio- and 34 are caused by a combination of abrasion (notice the presence of grooves corrosion (erosion), friction (abrasion), and and gingival recession) and erosion (notice no sharp boundary of the lesion at the stress (abfraction) (Figs 6 and 7). In addition, enamel side). These lesions often have a U shape. several risk factors can have an inﬂuence on the formation of NCCLs: saliva, tooth form, composition, microstructure, mobility, positional prominence, presence of restorations, magnitude, direction, frequency, site, and duration of the applied forces.4,13

Biocorrosion (erosion)

Biocorrosion of teeth can occur due to extrinsic acids (acidic foods and drinks, acidic mouth rinse, acidic medication) and/or intrinsic acids (gastric acid). In addition, proteolytic enzymes present in the crevicular Fig 5 Full ceramic crowns were placed on the four incisors 20 years previously. ﬂuid14 and proteolytic enzymes from the The patient is missing several posterior teeth. Notice the overeruption of teeth 11 stomach (pepsin) and pancreas (trypsin)15 and 12, which has resulted in abnormal occlusal loading on these teeth. Abfrac- released during vomiting can degrade the tion lesions are visible on teeth 11, 12, and 21. These lesions are typically wedge demineralized dentinal organic matrix. shaped, with sharp internal and external line angles and an apical extent relative to the CEJ. Risk factors are the composition and frequency of the intake of acids, the position and form of teeth in the dental arch, and the As there is overwhelming evidence that the presence of gingival recession. Saliva (pH, etiology of NCCLs is multifactorial, a combi- viscosity, ﬂow, composition, buffer capaci- nation of these differentg eometric forms ty) is an important risk factor in the develop- often presents (Figs 1b, 6, and 7).2-5 ment of NCCLs. The ions in saliva are able In general, the development of NCCLs to induce remineralization of demineralized tends to be a slow process occurring over tooth structure and can thus inhibit the for- an extended period of time, with pulpal re- mation of NCCLs. traction, sclerosis, and lack of dentin sensi- NCCLs are more common on facial sur- tivity among the consequences (Figs 1b, 6, faces of teeth than on lingual ones. A possi- and 7).10-12 ble explanation is the difference in chemis-

20 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 PEUMANS ET AL

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.

try and character of saliva in lingual areas Fig 7 (a to c) (more serous saliva – higher buffer capacity) Generalized extensive NCCLs in a 62-year- and facial areas (mucous saliva – lower buf- old male patient. fer capacity), which accounts for the differ- Examination pointed ences in remineralization of the tooth struc- to a multifactorial ture and the dilution of buffering acids.16 etiology. The occlusal Xerostomia and dehydration from perspira- a surfaces showed tion with physical activity create impaired wear facets with erosive cupping. The salivary ﬂow and inhibit the buffering of patient’s diet consists acids in the oral cavity. of many abrasive foods and he is Friction (abrasion) extremely fervent when cleaning his Friction or abrasion is the physical wear that teeth, resulting in extensive forces results from a mechanical process involving being applied during foreign objects. Different factors can be in- b tooth brushing. volved such as abrasive toothpaste, improp- Notice pronounced er tooth brushing using a horizontal tech- gingival recession and nique and excessive force, frequency of a traumatized gingiva brushing, stiffness of bristles, and particular in the maxillary anterior region. The dietary habits. The magnitude, direction, fre- cervical lesions in the quency, and duration of the applied forces mandible are shallow- are further risk factors in the development er, probably because of NCCLs. In addition, a prominent position of their more lingual of the tooth in the arch leaves it prone to position. Sclerotic excessive forces from tooth brushing.4,13 dentin is present in most lesions. From results of laboratory and clinical studies, there is little evidence that NCCLs are c solely caused by abrasion.2

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 21 CLINICAL RESEARCH

titatively strong study design are needed to prove a clear association between occlusion 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 magnitude, direction, frequency, site of application, and duration of a force, in addition to its orientation with respect to the principal axes of the teeth and their form, composition, and stability. Second, the cushioning

Fig 8 This patient showed several NCCLs. The maxillary first molar extends effect of the periodontal ligament is another beyond the occlusal plane. Occlusal overstress resulted in additional cervical modifying factor, as there is a negative cor- wear due to abfraction in the mandibular second premolar and the maxillary first relation between mobility and NCCLs. Third, molar. the weakening effect of an occlusal restoration may contribute to the development of Stress (abfraction) an abfraction lesion. Finally, the occlusal positional prominence of the teeth is anoth- The abfraction theory is based on a bio- er important factor in determining possible mechanical concept in which the cervical overstress and trauma (Fig 8). area of a tooth becomes a fulcrum during Most lesions are caused by an interac- occlusal function, bruxing, and parafunction of two or three causes that result in in- tional activity, causing tensile stresses in the creased cervical tooth wear, ie, the com- area where NCCLs occur. These stresses bined effect of erosion and abrasion is are thought to disrupt the crystalline struc- greater than the effect of either force oper- ture of the locally thin enamel and underly- ating on its own.29,30 It also appears that li- ing dentin by cyclic fatigue, leading to quid acid, frequently found in modern diets, cracks. Ultimately, the enamel breaks away may be necessary in order for occlusal load- at the cervical margin and progressively ex- ing to be a factor in the formation of cervi- poses the dentin, where the process contin- cal lesions.31 In addition, it is suggested that ues.13,17 This theory is quite controversial. biocorrosion plays a very important role in Several finite element analysis (FEA) studies the formation of NCCLs. have shown a clear correlation between oc- Clinicians should consider all etiologic clusion and NCCLs.18-22 In addition, several and risk factors before completing the diag- clinical trials also report strong evidence of nosis or initiating treatment, if indicated. an association between occlusal factors Practitioners should follow a checklist to de- and NCCLs (or their progression);23-26 never- termine the etiology of each particular lesion theless, two systematic reviews were unable in order to make as precise a diagnosis as to show a clear association.27,28 The large possible. Table 1 shows a simplified version heterogeneity among methodologies, the of the schema proposed by Grippo et al.13 lack of standardization, and differences in the diagnoses of NCCLs could contribute to Treatment options the weak evidence in these two reviews, both of which concluded that prospective To date, there is no conclusive evidence for clinical studies with a qualitatively and quan- reliable, predictable, and successful treat-

22 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 PEUMANS ET AL

Table 1 Etiology of Biocorrosion – erosion Chemical, biochemical, and electrochemical degradation of enamel and dentin NCCLs – checklist

Check Etiologic factors Risk factors

Diet • Acidic beverages and foods • Citrus fruits and juices

Profession • Wine tasting • Occupational exposure to acidic industrial gases • Composition and frequency of • Activities resulting in dehydration intake of acidic foods and drinks (eg, sport activities) • Buffering capacity, composition, flow rate, pH, and viscosity of Medical history • Gastroesophageal disease with reflux saliva • Anorexia or bulimia nervosa • Position and form of the teeth • Factors predisposing the patient to in the dental arch gastric reflux (eg, hiatus hernia, sport • Gingival recession activities) • A cidic 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 • Abrasive toothpaste • Magnitude, direction, frequen- practices • Tooth brushing technique cy, site, and duration of force • Stiffness of toothbrush bristles applied during tooth brushing • Frequency of brushing • Position and form of the teeth • Incorrect hygiene habits in the dental arch • Gingival recession

Dental appliances Clasps of prostheses

Abfraction – stress Tensile stress at the cervical area during occlusal loading

Occlusal • Parafunction (eg, bruxism, clenching) • Magnitude, direction, frequen- examination • Excessive functional load cy, site, and duration of the • Malocclusion applied forces • Premature contacts • Mobility of the teeth • Eccentric loading • Presence of occlusal restor- • Habits (eg, biting on hard objects) ations • Mastication of hard and resistant food substances

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 23 CLINICAL RESEARCH

ment regimens for NCCLs. The current movements, force, premature contacts, knowledge and available treatment strat- type of guidance, and slide of centric occlu- egies for NCCLs are discussed below, with a sion to maximum intercuspation). In two focus on prevention, monitoring, treatment systematic reviews,27,28 several authors ad- of dentin hypersensitivity, restorative treat- vise that any decision to carry out a destruc- ment, and root coverage surgical proced- tive, irreversible treatment such as occlusal ures with or without restorative treatment. adjustment should be considered very care- fully.1,4,5,28 If abfraction is suspected to be a Prevention dominant factor in the etiology of NCCLs, the most conservative treatment option The objectives of preventive therapy are to suggested is an occlusal splint as this re- prevent the progression of existing lesions duces the amount of nocturnal bruxism and or the development of new ones and to as- nonaxial tooth forces,4,5 although in this sure the longevity of restorations in restored case too there is no scientific evidence to lesions. Preventive interventions include support the use of an occlusal splint. On the counseling for changes in the patient’s be- other hand, Soares and Grippo33 state that havior depending on the etiology (abrasion, preventive management strategies should erosion, and/or abfraction).4,13,32 consider occlusal therapy in patients with Cervical abrasions are generally thought parafunctional habits and occlusal prema- to be a consequence of tooth brushing fac- turities. According to these authors, occlu- tors such as frequent or forceful brushing, sal therapy can mitigate the development of faulty or vigorous techniques, filament stiff- NCCLs by correcting occlusal imbalance ness or design, dominant hand dexterity, or and removing occlusal prematurities. They abrasive dentifrices. Patients should be in- emphasize that occlusal therapy must be formed about these factors and, where nec- carried out with a thorough knowledge of essary, advised to alter their brushing mater- the occlusion. ials or habits. In addition, patients should be instructed to avoid brushing immediately Monitoring after an erosive challenge. Dental erosion can also be effectively The activity of NCCLs needs to be assessed modified and should be correctly diagnosed. and considered in the treatment planning Treatment success depends on the patient’s process. It is known that the progression of collaboration.4,13 When erosion is caused by NCCLs is generally slow, but with a large eating disorders or gastroesophageal reflux variation among patients.26,34,35 Therefore, disease, the treatment may require the par- an individual monitoring protocol should be ticipation of a physician. The extrinsic etiolo- established that assesses the severity of the gy is more easily treatable. During the diag- present lesions, the patient’s age, and the nostic phase, the checklist (Table 1) must be existing etiologic and risk factors. For pa- followed to see which external erosive fac- tients who are exposed to intrinsic acids or tors exist. Removing or altering harmful who present with rapid progression, the as- habit/s provides consistent results. sessment procedure of lesion activity should For NCCLs with an abfraction etiology, be repeated at 6-month intervals during there is no consensus on preventive treat- regular hygiene. For most other cases, an- ment strategies. On the one hand, there is a nual assessment is acceptable (Fig 9). weak association between NCCLs and oc- Approaches to determine lesion activity clusal factors (interference in excursive include the use of standardized intraoral

24 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 PEUMANS ET AL

photographs, possibly study models, and the measurement of lesion dimensions (width/length) over time. With the recent introduction of digital dentistry, computer-aided design/computer-aided manufac- turing (CAD/CAM) systems may be useful for the diagnosis of NCCLs and in monitoring 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 a relative occlusal force in the maximum intercuspation position.26 No significant correlation was found between NCCL progression 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. b In another in vivo study evaluating 10 lesions in six patients over a period of 4 to Fig 9 (a and b) Several small NCCLs in the posterior region in a 35-year-old 5 years, dimensional analysis showed nota- patient due to a combination of abfraction and abrasion. The patient showed ble progression in deeper lesions.35 In addi- signs of bruxism for which an occlusal splint was made. As the lesions were tion, wedge-shaped lesions were reported stable during the yearly follow up, no treatment was needed. 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 ones due to the higher stress development V-shaped lesions showed higher stress lev- of deeper lesions that results in their more els concentrated at the zenith of the lesion, notable progression. whereas in U-shaped defects the stresses were concentrated over a wider area.As the Treatment of dentinal lesions advanced in depth, the stress was hypersensitivity amplified at their deepest part. A trend of stress amplification was also observed with Dentinal hypersensitivity is a symptom often decreasing bone height. associated with early stages of NCCLs. If the One should bear in mind that restorative lesions are small and shallow and require no treatment may be indicated at an earlier restorative treatment, and should sensitivity stage for V-shaped lesions than for U-shaped persist, the hypersensitive tooth must first ones in patients with a heavy occlusion be treated in a noninvasive way. There is a and articulation. Restoring deeper (1.5 mm) broad spectrum of relatively cost-effective NCCLs is usually prioritized over shallower at-home desensitizing agents available on

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 25 CLINICAL RESEARCH

hypersensitivity and promote remineralization 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 results; however, confirmation in clinical trials a is required. Finally, resin-based dental adhesive systems can also provide a longer-lasting dentin-desensitizing effect compared with the use of home-desensitizing agents.4,5,36,40 The adhesive resins can effectively seal the dentinal tubules by forming a hybrid layer. Vari- ous clinical studies have demonstrated the effectiveness up to6 months of adhesives in the management of dentin hypersensitivity.40,41 b Restorative treatment 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 Restorative treatment of NCCLs should be powder and liquid according to the manufacturer’s instructions and apply the considered when one or more of the fol- slurry for at least 30 s. Rinse off with water spray or allow the patient to rinse. lowing conditions are present: 1) active, cavitated caries lesions associated with NCCLs; 2) cervical lesion margins or all le- the market that show different mechanisms sion margins are located subgingivally and of action: nerve desensitization (eg, potassi- preclude plaque control, hence the risk of um nitrate), protein precipitation (eg, glutar- caries and periodontal disease increases; aldehyde, silver nitrate, zinc chloride, stron- 3) extensive tooth structure loss, which tium chloride hexahydrate), and plugging compromises the integrity of the tooth, or the dentin tubules (eg, sodium fluoride, the defect is in close proximity to the pulp, stannous fluoride, strontium chloride, po- or the pulp has been exposed; 4) persistent tassium oxalate, calcium phosphate, calci- dentinal hypersensitivity in which noninva- um carbonate, bioactive glass).36 These sive therapeutic options have failed; 5) pros- agents include toothpastes, mouth washes thetic abutment for removable prosthesis; and chewing gums. The results of at-home and 6) esthetic demands by patients.5,32 If desensitizing therapy should be reviewed there is a need for a restoration, NCCLs after 3 to 4 weeks. If there is no relief from should be restored as minimally invasively dentinal hypersensitivity, in-office therapy as possible. Of the available restorative tech- should be initiated. Recently, the in-office niques, an adhesive system, combined with application of calcium- and phosphate- a composite resin, is the preferred choice of based systems was introduced to decrease practitioners due to the good esthetic prop-

26 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 PEUMANS ET AL

Fig 11 patient with extensive cervical abrasion lesions on all her teeth. The exposed dentin surfaces showed hypersensitivity. 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, a 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 b c 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 restorations will be placed, followed by a root coverage surgical procedure (CTG and CAF).

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 27 CLINICAL RESEARCH

erties and clinical performance of composite 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 a parameters determine the clinical behavior of these restorations. According to a systematic review evaluating the clinical effectiveness of contemporary adhesives in NCCLs, the selection of the adhesive system is an important factor determining the durability of the restoration.43 Apart from the selection of the adhesive system, the operator plays a decisive role. The operator has to take care that a high-quality clinical pro- b cedure is carried out: isolation, tooth preparation, application of the adhesive system

Fig 12 (a) A 70-year-old female patient showing NCCLs on all her mandibular and composite, ﬁnishing, polishing, and ﬁ- anterior teeth. The etiology was multifactorial, with abrasion being the main nally maintenance of the restoration. These etiologic factor. The exposed dentin was not hypersensitive. The reason for the different parameters are successively dis- treatment with direct composite restorations was to improve esthetics. (b) Apart cussed in detail below. from the small lesion on tooth 43, all the NCCLs were restored with a nanohybrid composite in combination with a mild 2SEa. 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 adhesives (E&Ra), self-etch adhesives (SEa), and restorative materials with a self-adhesive approach (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 level demineralizes up to a depth of a few mi- crometers to expose a HAp-deprived collagen mesh. The next step involves either a separate priming step followed by the application/curing of a combined primer/adhe- Fig 13 Two mandibular premolars with 20-year-old Class V composite restor- sive resin using a 2-step procedure (2E&Ra), ations. A 3E&R adhesive system was used in combination with a microfilled composite (first premolar) and a hybrid composite (second premolar). After or a separate primer and adhesive resin fol- 20 years, the restorations are still clinically acceptable, presenting slight marginal lowing a 3-step procedure (3E&Ra). The final defects and superficial marginal discoloration. objective is to micromechanically interlock

28 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 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 procedure (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 surface 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 Fig 14 Classification of contemporary adhesives according to Van Meerbeek chemically interacting with the HAp.46 This et al.44,45 results in a twofold micromechanical and chemical bonding mechanism. Of all com- ization. Chemical bonding is additionally mercially available functional monomers, obtained by ionic interaction of the carboxyl 10-MDP has been proven to be the most groups of the polyalkenoic acid with the effective one, able to form a stable and du- calcium of the HAp that remains attached to rable chemical bond with HAp in the hybrid the collagen fibrils. Most of the glass-iono- layer.47 E&Ra and SEa are combined with a mers and resin-modified glass-ionomers are restorative material (a composite resin, a available as restorative materials. giomer or a compomer). Other self-adhesive materials are the so- Glass-ionomers (GIs) and resin-modified called self-adhesive luting composites, most GIs are self-adhesive materials. A short poly- of which are available as luting agents. alkenoic acid pretreatment is recommend- Self-adhesive flowables were introduced ed, resulting in a 2-step approach. The poly- onto the dental market some years ago, but alkenoic acid conditioner cleans the tooth the in vitro bonding efficiency to tooth surface. It removes the smear layer and ex- structure is below the level of that recorded poses collagen fibrils up to a depth of about for the commonly used adhesive systems 0.5 to 1 μm, where GI components inter- described above.48 diffuse and a micromechanical bond is es- Nowadays, there is a major trend to use tablished following the principle of hybrid- universal adhesives, which are actually a

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 29 CLINICAL RESEARCH

newer version of 1SEa_m that can be applied 1SEa_m. These results accord with those of in different modes: an etch-and-rinse mode, a systematic review that evaluated the bond- a self-etch mode, and a self-etch mode with ing effectiveness of adhesives in vitro ac- prior selective etching of the enamel margin cording to microtensile bond strength with 35% phosphoric acid.49,50 tests.51 Similarly, Optibond FL and Clearfil SE NCCLs are the most ideal lesions to test Bond showed the best results regarding im- the clinical effectiveness of adhesives in clin- mediate bond strength and bond strength ical trials.43 These lesions involve both enam- after 1 year of water storage. el and dentin; however, the largest part of Although GI-based materials perform the tooth structure on which to bond con- well with regard to retention, their rather sists of dentin. These lesions commonly do poor esthetic properties, inferior wear resis- not provide any (or they provide minimal) tance, and solubility particularly in acidic macroretention, so ineffective bonding will oral environments may make them less ad- result in debonding and thus restoration equate for restoring NCCLs, especially in loss. Loss of retention is the key objective the anterior and premolar regions.42,43 parameter against which the bonding performance of adhesives in NCCL clinical trials Isolation is evaluated. In a systematic review of NCCL clinical trials, the number of lost restorations Proper isolation is important for the success per year (calculated as annual failure rate of NCCL restorations. A recently published [AFR]) was recorded in 87 clinical trials evalu- meta-analysis stated that the use of rubber ating 78 different adhesives.43 The adhesives dam positively influences the performance were classified into seven different classes: of adhesive NCCL restorations, resulting in 3E&R, 2E&R, 2SEa_m; 2SEa_s, 1SEa_m, less retention loss and better marginal adap- 1SEa_s, and GI. SEa_m contains the inter- tation.52 Therefore, if the clinical situation al- mediate, mild, and ultra-mild SEa (described lows, absolute isolation with rubber dam on the previous page). The first conclusion should be applied. A good strategy has to be was that the adhesive strategy is a determin- followed, with the practitioner aware of the ing factor for the clinical bonding effective- tips and trips to correctly isolate under rub- ness in NCCLs. The best-performing classes ber dam.53 For this procedure, the use of were GI, with the lowest AFR score, followed heavy rubber dam is preferred as it results in closely by 2SEA_m, 3E&R, and 1SEA_m. An the best retraction of the peripherical tissues, inadequate bonding effectiveness was on - including the papilla. The holes must be ticed for 2E&Ra, 1SEa_s, and 2SEa_s. It is punched correctly so that all gingival tissues obvious that the chemical bonding poten- are covered. Inverting the rubber dam around tial of adhesives is important for the quality the neck of the tooth prevents the saliva and durability of the bond in NCCLs. In ad- from leaking in between the rubber dam and dition to the adhesive strategy, a wide varia- the gingiva. Useful clamps for rubber dam tion exists between the adhesives them- isolation of NCCLs are the Brinker Clamps selves. Practitioners should therefore select (Tissue Retractors) (B4, B5, B6) (Hygenic; a product that has a good proven clinical Coltene Whaledent) and Clamp 212 (Hu performance. In the best-performing adhe- Friedy). In addition, floss, teflon tape, and gin- sive categories described above, the lowest gival retraction cord can be used to obtain AFR scores were recorded for Optibond FL additional gingival retraction (Figs 15 and 16). (Kerr) for 3E&Ra, Clearfil SE Bond (Kuraray Intrinsic anatomical and morphological Noritake) for 2SEa_m, and G-Bond (GC) for characteristics of the cervical region can cre-

30 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 PEUMANS ET AL

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 a b visible.

ate limitations in the placement of the rubber Fig 16 (a) Tooth 31: dam and clamp. Difficulties can occur, for Additional retraction was realized with instance, when restoring a NCCL on a molar teflon tape. Regard- or on other teeth with a very large difference ing tooth preparation, in height between the buccal and lingual gin- a short enamel bevel giva or when teeth are severely crowded. (1 to 2 mm) was When adequate rubber dam isolation is made with a not possible, another isolation method diamond bur. The dentin surface was should be employed. The insertion of a gin- roughened with a gival retraction cord in combination with small round cotton rolls can help to control moisture. A diamond bur. The a blood and hemostatic agent can be used sharp area in the when needed to control blood contamina- depth of the lesion tion. Some studies have demonstrated that was smoothened. (b) Air abrasion of the dentin contamination with ferric sulfate or roughened enamel aluminum chloride decreases the bond and dentin surface strength of self-etch adhesives.54,55 Groddeck with Al2O3 (27 μm) et al56 showed that cavity contamination with (Aquacare; Velopex) hemostatic agents, applied after blood con- resulted in a clean tamination and removed with water spray, prepared tooth surface. The does not compromise marginal adaptation adjacent teeth were in enamel and dentin when using an E&Ra or protected with a 56 an SEa, although element surface analysis metal matrix band. showed that remnants of hemostatic agents b were found on enamel and dentin surfaces after rinsing the dark coagulum with water spray. Apparently, remnants of hemostatic Tooth preparation agents on the surface of dental hard tissues might have less influence on marginal adap- Preparation of the enamel side tation than on bond strength. A last option is At the incisal side, the composite material a proposed association of a plastic or metal will be bonded to enamel. A short enamel matrix with wooden wedges and a photo- bevel (1 to 2 mm) should be prepared using cured gingival barrier.57 a microfine diamond bur (Fig 16a). This re-

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 31 CLINICAL RESEARCH

the smear layer. The creation of a thick smear layer can interfere with the bonding efficiency of mild/ultra-mild (pH ≥ 2) self-etch adhesives.61 Therefore, to ensure a clean roughened tooth surface with a minimal thickness smear layer, tooth preparation should be ﬁ- nalized using airborne-particle abrasion with

Al2O3 powder (27 or 50 μm) (Fig 16 b). Air Fig 17 After isolation with gingival retraction cords and cotton rolls, the abrasion is reported to increase the surface contaminated layer on the dentin surface of the NCCLs is clearly visible. This area available for adhesion, improve resin ad- layer must be removed by roughening with a diamond bur or with Al O (27 μm) 2 3 aptation, and enhance resin tag forma- to create a clean dentin surface that is perceptible for a good-quality adhesive tion.62-64 Several in vitro studies have shown bond. an increased bond strength to dentin when using an E&Ra or SEa.63-66 Other in vitro stud- moves the aprismatic enamel and increases ies, however, measured no significant influ- the bond strength to enamel.58 In addition, ence of air abrasion on the bond strength to placement of an enamel bevel will result in enamel and dentin (also for E&Ra and SEa),69 a more gradual transition between the com- not even after aging.69 posite restoration and tooth surface, improv- In general, the preparation must be kept ing the final esthetic outcome. as minimally invasive as possible by only roughening the enamel and dentin surfaces. Preparation of the dentin surface However, in sharp, wedge-shaped NCCLs in The dentin surface of NCCLs is often scle- teeth with heavy occlusal loading, rounding rotic and is a more difficult substrate to the depth of the angular lesion can be justi- bond to than sound dentin. Sclerotic dentin fied to improve the biomechanical behavior is hypermineralized and has a shiny and firm of the restorative material and consequently appearance. The dentin tubules are partially promote clinical longevity (Fig 16).18,19 or completely occluded by mineral depos- its, resulting in a higher resistance to acid Application of the adhesive system dissolution. Morphological evaluation of the resin–sclerotic dentin interface shows a thin The adhesive system must be applied strict- hybrid layer at the hypermineralized intertu- ly according to the manufacturer’s instruc- bular dentin, and short and barely devel- tions (Figs 18 to 20). When using a non-sim- oped resin tags.59 plified adhesive (3E&Ra, 2SEa), the primer To increase the bonding effectiveness to must be applied vigorously and rigorously this type of dentin, the superficial sclerotic to the dentin surface for the amount of dentin should be roughened with a dia- time indicated by the manufacturer. An op- mond bur (Fig 16a).52 Another important rea- timized wetting and penetration of the ex- son to roughen the dentin surface is to re- posed dentin surface will result in the for- move the contaminated layer observed on mation of a good-quality hybrid layer. The most NCCLs during microscopic evaluation importance of this step is often underesti- of extracted teeth (Fig 17).11,60 This layer re- mated. sists adhesion and should therefore be re- When using a mild SEa system, the best moved. clinical performance will be obtained when The roughness of the diamond bur is im- the incisal enamel is selectively etched with portant as this can influence the thickness of 35% phosphoric acid (Fig 18). Small marginal

32 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 PEUMANS ET AL

Fig 18 (a) Tooth 31: 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

Fig 19 (a) Tooth 31: 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

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 33 CLINICAL RESEARCH

defects and superficial marginal discolor- composite or a flowable resin that has a low ation will present less frequently at the incisal modulus of elasticity because these will flex enamel side with aging.43 Etching enamel with the tooth and not compromise reten- with phosphoric acid creates a deeper and tion. However, no definitive conclusion can more pronounced etch pattern compared be found in the literature that addresses the with SEa and results in an increased micro- difference between failure rates of resin mechanical retention and a more optimal composites of different stiffness used toe r - bond to enamel. store NCCLs.71,72 Selecting a universal adhesive, a 10-MDP- based adhesive is preferred, used in a self- Application of the composite etch mode with prior selective etching of A multiple layering technique with a con- the enamel. The chemical interaction be- ventional composite has been proposed to tween the 10-MDP functional monomer restore deeper and/or larger lesions to min- and calcium is only possible when HAp re- imize shrinkage due to polymerization and mains in the hybrid layer. All HAp is dissolved also to achieve better marginal adaptation when one follows the E&R approach. in Class V non-carious lesions. Several in vi- Finally, when using a simplified adhesive tro studies70,73,74 have shown that the best system, it is best to cover the adhesive with a results are obtained when using the oblique hydrophobic resin coating. The use of this ad- layering technique from gingival toward in- ditional coating after the application of a sim- cisal. This technique has been applied in plified adhesive system leads to a thicker and most NCCL clinical trials.43 Indeed, since more uniform adhesive layer with less re- enamel adhesion is stronger, more stable, tained water and solvent and a significant re- and more predictable, the insertion of ma- duction in the fluid flow rate. In this way, a terial should begin from the gingival wall, more stable resin–dentin interface is formed.43 without the surrounding enamel. Whenever possible, the cavity should be restored with Selection and application three or two increments (Figs 21 to 25). The of the composite last one should be placed on the enamel margin. Small lesions can be restored with Selection of the composite one increment. NCCLs have a relatively small C-factor, An alternative application method is to meaning that the mechanical properties of cover the entire exposed dentin surface the composite are less important to the out- with a thin layer of flowable composite in a come of the final restoration than the actual first step to optimize the adaptation of the performance of the adhesive. Indeed, sever- composite to the hybridized dentin surface. al reviews have shown that the type of com- In addition, the lower e-modulus and higher posite used had no influence on the bond- flexibility of the flowable composite will ing performance of adhesives in NCCLs.42,43,70 compensate for polymerization shrinkage. Similarly, compomers and giomers, both Next, the rest of the lesion should be re- fluoride-releasing resin materials, do not stored with a stiffer conventional composite show a better performance compared with (Figs 24 and 25). conventional composites in NCCL clinical As far as esthetics is concerned, the col- trials.42,43 or of the cervical area is easy to obtain. The It has been stated that NCCLs suspected use of a medium opacity chromatic dentin of being caused primarily by abfraction composite covered with a more translucent should be restored with a microfilled resin slightly chromatic enamel composite – also

34 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 PEUMANS ET AL

a b

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.

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 35 CLINICAL RESEARCH

a b

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.

abc

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.

36 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 PEUMANS ET AL

called achromatic enamel75 – copies the tion of rubber polishing points with a de- natural tooth structure (Figs 21 to 23). Most creasing grit size (Fig 26). practitioners prefer a simplified color build When a Class V restoration is performed up and use just one chromatic body com- in a semi-direct way, as described by Fahl76 posite with medium opacity. and Ritter et al,77 the composite restoration A careful placement technique is need- is made and finished extraorally and is then ed to minimize the finishing procedure. bonded with a luting composite. The extra- oral finishing and polishing of these Class V Finishing and polishing inlays simplify the finishing procedure of the restoration after cementation. According to Any excess or roughness should be avoided these authors, this technique more easily in NCCL restorations. Plaque retention, gin- provides a high surface smoothness and a gival inflammation, and the occurrence of good marginal adaptation compared with caries lesions represent not only a failure of the commonly used direct technique. How- the restoration but also a creation of new ever, clinical studies are required to prove problems for the patient. Poorly performed whether this technique is superior to the finishing and polishing procedures can lead clinically proven direct technique. to soft and hard tissue damage. Techniques that require a minimal amount of finishing Maintenance and polishing are ideal, but properly con- toured restorations are seldom achieved The condition of the restorations must be without removing excess material, especial- evaluated yearly. Marginal deterioration that ly at the margins. When needed, a good op- presents as marginal discoloration and small tion is to use a microfine diamond finishing marginal defects is commonly seen in these point (40 μm grit size), then a coarse com- restorations with aging;43,78 their lifespan can posite finishing disc, and finally the applica- be lengthened by repolishing the restor-

abc

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.

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 37 CLINICAL RESEARCH

a b

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.

ation margins (Fig 27). If larger defects are bined restorative-surgical approach, the res- present, local repair is indicated. toration must be placed prior to the surgical The influence of the patient factor on procedure for better visibility of the opera- the clinical performance of the restorations tive field and for the finished restoration. To should not be underestimated. As already properly restore the dental tissue lost due to mentioned, the etiology of the NCCLs must wear, the maximum level of root coverage always be kept under control to prevent re- needs to be predetermined.79,80 currence of the lesions. Importantly, special The restoration should recreate not only conditions such as poor oral hygiene, high the contour of the tooth crown but also that caries risk, heavy bruxism, and erosive chal- of the lost CEJ at the root portion. Recent lenges were not included in most NCCL systematic reviews have pointed out that clinical trials. Although one expects that the combination of a coronally advanced these high-risk patient factors negatively in- flap (CAF) with connective tissue graft (CTG) fluence the lifespan of the restorations to a provides the best clinical outcomes for root large extent, the clinical longevity of resin coverage when appropriately performed.79,80 composites as restorative materials in such However, there is still a lack of long-term a context has not yet been clinically investi- clinical evidence to prove the stability of the gated. combined perio-restorative approach.

Root coverage surgical Conclusion procedures in combination with a restoration To achieve an accurate diagnosis of the etiology of multifactorial NCCLs, practition- NCCLs may be associated with gingival re- ers should follow the following checklist: cession, exposing root surfaces to the oral comprehensive medical and dental history, cavity. Placement of a composite restor- occlusal examination, evaluation of diet, ation is possible, but the esthetic result can and oral hygiene procedures. Furthermore, be disappointing. If esthetics is important to important risk factors in the formation of the patient, the ideal treatment for the NCCLs should be taken into account. combination of noncarious cervical lesions Treating NCCLs necessarily involves (particularly in the case of deep lesions) and problem identiﬁcation, diagnosis, etiologic gingival recession is a combined perio- factor removal, monitoring, and, if neces- restorative approach (Fig 28).32,79,80 In a com- sary, treatment. Personalized treatment

38 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 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 a deep defects on teeth 14, 15, 16, and 26 were ﬁrst restored with direct composite restorations until the level of the CEJ. (b) Initial situation: Lateral view, with NCCLs on several teeth. (b) After placement of direct composite restorations on teeth 14, 15, and 16 (restoring c b 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 d (combination of CTG and CAF) on teeth 13, 14, 15, and 16.

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 39 CLINICAL RESEARCH

should be applied, with the appropriate ap- with a good proven clinical performance is proach adopted for the speciﬁc situation. selected. In addition, a high level of oper- Particular attention should be paid to the ator skill combined with a careful operative preventive phase, as this will also determine procedure is required to enhance the lon- the longevity of the restorative treatment. gevity of the restorations. When function and esthetics are impaired, In case NCCLs are associated with gingi- direct composite restorations are indicated val recession, the original soft and hard tis- to restore deep lesions. These restorations sue relation and structure can be restored show an acceptable clinical performance in esthetically and functionally by a combined the long term provided an adhesive system perio-restorative intervention.

References

1. Michael JA, Townsend GC, Greenwood 10. Daley TJ, Harbrow DJ, Kahler B, Young anical behaviour of maxillary incisors. Aust LF, Kaidonis JA. Abfraction: separating fact WG. The cervical wedge-shaped lesion Dent J 2013;58:306–314. from fiction. Aust Dent J 2009;54:2–8. in teeth: a light and electron microscopic 19. Soares PV, Machado AC, Zeola LF, et al. 2. Bartlett DW, Shah P. A critical review of study. Aust Dent J 2009;54:212–219. Loading and composite restoration assess- non-carious cervical (wear) lesions and the 11. Michael JA, Kaidonis JA, Townsend GC. ment of various non-carious cervical lesions role of abfraction, erosion, and abrasion. Non-carious cervical lesions: a scanning morphologies – 3D finite element analysis. J Dent Res 2006;85:306–312. electron microscopic study. Aust Dent J Aust Dent J 2015;60:309–316. 3. Levitch LC, Bader JD, Shugars DA, Hey- 2010;55:138–142. 20. Guimarães JC, Guimarães Soella G, mann HO. Non-carious cervical lesions. 12. Walter C, Kress E, Götz H, Taylor K, Brandão Durand L, et al. Stress amplifica- J Dent 1994;22:195–207. Willershausen I, Zampelis A. The anatomy tions in dental non-carious cervical lesions. 4. Pecie R, Krejci I, Garcia-Godoy F, Bor- of non-carious cervical lesions. Clin Oral J Biomech 2014;47:410–416. tolotto T. Noncarious cervical lesions – a Investig 2014;18:139–146. 21. Jakupovic S, Cerjakovic E, Topcic A, clinical concept based on the literature 13. Grippo JO, Simring M, Coleman TA. Ajanovic M, Prcic AK, Vukovic A. Analysis of review. Part 1: prevention. Am J Dent Abfraction, abrasion, biocorrosion, and the the abfraction lesions formation mechanism 2011;24:49–56. enigma of noncarious cervical lesions: a by the finite element method. Acta Inform 5. Wood I, Jawad Z, Paisley C, Brunton P. 20-year perspective. J Esthet Restor Dent Med 2014;22:241–245. Non-carious cervical tooth surface loss: a 2012;24:10–23. 22. Romeed SA, Malik R, Dunne SM. Stress literature review. J Dent 2008;36:759–766. 14. Hara AT, Ando M, Cury JA, Serra MC, analysis of occlusal forces in canine teeth 6. Bernhardt O, Gesch D, Schwahn C, et al. González-Cabezas C, Zero DT. Influence of and their role in the development of Epidemiological evaluation of the multifac- the organic matrix on root dentine erosion non-carious cervical lesions: abfraction. torial aetiology of abfractions. J Oral Rehabil by citric acid. Caries Res 2005;39:134–138. Int J Dent 2012;2012:234845. 2006;33:17–25. 15. Schlueter N, Hardt M, Klimek J, Ganss 23. Telles D, Pegoraro LF, Pereira JC. Prev- 7. Borcic J, Anic I, Urek MM, Ferreri S. The C. Influence of the digestive enzymes alence of noncarious cervical lesions and prevalence of non-carious cervical lesions trypsin and pepsin in vitro on the progres- their relation to occlusal aspects: a clinical in permanent dentition. J Oral Rehabil sion of erosion in dentine. Arch Oral Biol study. J Esthet Dent 2000;12:10–15. 2004;31:117–123. 2010;55:294–299. 24. Pegoraro LF, Scolaro JM, Conti PC, Telles 8. Yang J, Cai D, Wang F, et al. Non-cari- 16. Young WG, Khan F. Sites of dental D, Pegoraro TA. Noncarious cervical lesions ous cervical lesions (NCCLs) in a random erosion are saliva-dependent. J Oral Rehabil in adults: prevalence and occlusal aspects. sampling community population and the 2002;29:35–43. J Am Dent Assoc 2005;136:1694–1700. association of NCCLs with occlusive wear. 17. Rees JS, Hammadeh M, Jagger DC. Ab- 25. Antonelli JR, Hottel TL, Brandt R, Scar- J Oral Rehabil 2016;43:960–966. fraction lesion formation in maxillary incisors, becz M, Patel T. The role of occlusal loading 9. Zuza A, Racic M, Ivkovic N, et al. Preva- canines and premolars: a finite element in the pathogenesis of non-carious cervical lence of non-carious cervical lesions among study. Eur J Oral Sci 2003;111:149–154. lesions. Am J Dent 2013;26:86–92. the general population of the Republic of 18. Soares PV, Santos-Filho PC, Soares CJ, 26. Sawlani K, Lawson NC, Burgess JO, et Srprska, Bosnia and Herzegovina. Int Dent J et al. Non-carious cervical lesions: influence al. Factors influencing the progression of 2019;69:281–288. of morphology and load type on biomech- noncarious cervical lesions: a 5-year pro-

40 | The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 PEUMANS ET AL

spective clinical evaluation. J Prosthet Dent 39. Zhu M, Li J, Chen B, et al. The effect of 51. De Munck J, Mine A, Poitevin A, et 2016;115:571–577. calcium sodium phosphosilicate on dentin al. Meta-analytical review of parameters 27. Senna P, Del Bel Cury A, Rösing C. hypersensitivity: a systematic review and involved in dentin bonding. J Dent Res Non-carious cervical lesions and occlusion: meta-analysis. PLoS One 2015;10:e0140176. 2012;91:351–357. a systematic review of clinical studies. J Oral 40. Veitz-Keenan A, Barna JA, Strober 52. Mahn E, Rousson V, Heintze S. Me- Rehabil 2012;39:450–462. B, et al. Treatment for hypersensitive ta-analysis of the influence of bonding 28. Silva AG, Martins CC, Zina LG, et al. The noncarious cervical lesions: a Practitioners parameters on the clinical outcome of association between occlusal factors and Engaged in Applied Research and Learn- tooth-colored cervical restorations. noncarious cervical lesions: a systematic ing (PEARL) Network randomized clinical J Adhes Dent 2015;17:391–403. review. J Dent 2013;41:9–16. effectiveness study. JA m Dent Assco 53. Browet S, Gerdolle D. Precision and 29. Azzopardi A, Bartlett DW, Watson TF, 2013;144:495–506. security in restorative dentistry: the synergy Sherriff M. The measurement and pre- 41. Prati C, Cervellati F, Sanasi V, Monte- of isolation and magnification. Int J Esthet vention of erosion and abrasion. J Dent bugnoli L. Treatment of cervical dentin Dent 2017;12:172–185. 2001;29:395–400. hypersensitivity with resin adhesives: 4-week 54. Ajami AA, Kahnamoii MA, Kimyai S, et 30. Eisenburger M, Shellis RP, Addy M. Com- evaluation. Am J Dent 2001;14:378–382. al. Effect of three different contamination parative study of wear of enamel induced 42. Pecie R, Krejci I, García-Godoy F, removal methods on bond strength of a by alternating and simultaneous combina- Bortolotto T. Noncarious cervical lesions self-etching adhesive to dentin contaminat- tions of abrasion and erosion in vitro. Caries (NCCL) – r clinical concept based on the ed with an aluminum chloride hemostatic Res 2003;37:450–455. literature review. Part 2: Restoration. agent. J Contemp Dent Pract 2013;14:26–33. 31. Leal NMS, Silva JL, Benigno MIM, Be- Am J Dent 2011;24:183–192. 55. Kuphasuk W, Harnirattisai C, merguy EA, Meira JBC, Ballester RY. How 43. Peumans M, De Munck J, Mine A, Senawongse P, Tagami J. Bond strengths of mechanical stresses modulate enamel de- Van Meerbeek B. Clinical effectiveness of two adhesive systems to dentin contami- mineralization in non-carious cervical lesions? contemporary adhesives for the restoration nated with a hemostatic agent. Oper Dent J Mech Behav Biomed Mater 2017;66:50–57. of non-carious cervical lesions. A systematic 2007;32:399–405. 32. Terry DA, McGuire MK, McLaren E, review. Dent Mater 2014;30:1089–1103. 56. Groddeck S, Attin T, Tauböck TT. Effect Fulton R, Swift EJ Jr. Perioesthetic approach 44. Van Meerbeek B, De Munck J, of cavity contamination by blood and to the diagnosis and treatment of carious Yoshida Y, et al. Buonocore memorial hemostatic agents on marginal adaptation and noncarious cervical lesions: Part I. lecture. Adhesion to enamel and dentine: of composite restorations. J Adhes Dent J Esthet Restor Dent 2003;15:217–232. current status and future challenges. 2017;19:259–264. 33. Soares PV, Grippo JO. Noncarious Cer- Oper Dent 2003;28:215–235. 57. Perez CR. Alternative technique for class vical Lesions and Cervical Dentin Hypersen- 45. Van Meerbeek B, Peumans M, Poitevin V resin composite restorations with mini- sitivity. Etiology, Diagnosis, and Treatment. A, et al. Relationship between bond-strength mum finishing/ polishing procedures. Oper Quintessence Publishing, 2017. tests and clinical outcomes. Dent Mater Dent 2010;35:375–379. 34. Aw TC, Lepe X, Johnson GH, Mancl 2010;26:e100–e121. 58. Brännström M, Nordenvall KJ, Malmgren L. Characteristics of noncarious cervical 46. Yoshida Y, Nagakane K, Fukuda R, et al. O. The effect of variousp retreatment meth- lesions: a clinical investigation. J Am Dent Comparative study on adhesive perfor- ods of the enamel in bonding procedures. Assoc 2002;133:725–733. mance of functional monomers. J Dent Res Am J Orthod 1978;74:522–530. 35. Sugita I, Nakashima S, Ikeda A, et al. A 2004;83:454–458. 59. Tay FR, Pashley DH. Resin bonding to pilot study to assess the morphology and 47. Yoshihara K, Yoshida Y, Hayakawa S, et cervical sclerotic dentin: a review. J Dent progression of non-carious cervical lesions. al. Nanolayering of phosphoric acid ester 2004;32:173–196. J Dent 2017;57:51–56. monomer on enamel and dentin. Acta 60. Abdalla R, Mitchell RJ, Ren YF. Non-car- 36. Miglani S, Aggarwal V, Ahuja B. Dentin Biomater 2011;7:3187–3195. ious cervical lesions imaged by focus varia- hypersensitivity: recent trends in manage- 48. Poitevin A, De Munck J, Van Ende A, et tion microscopy. J Dent 2017;63:14–20. ment. J Conserv Dent 2010;13:218–224. al. Bonding effectiveness of self-adhesive 61. Ermis RB, De Munck J, Cardoso MV, et 37. Endo H, Kawamoto R, Takahashi F, et al. composites to dentin and enamel. Dent al. Bond strength of self-etch adhesives to Evaluation of a calcium phosphate desensi- Mater 2013;29:221–230. dentin prepared with three different dia- tizer using an ultrasonic device. Dent Mater 49. Rosa WL, Piva E, Silva AF. Bond strength mond burs. Dent Mater 2008;24:978–985. J 2013;32:456–461. of universal adhesives: a systematic review 62. Freeman R, Varanasi S, Meyers IA, 38. Sauro S, Watson TF, Thompson I. Den- and meta-analysis. J Dent 2015;43: Symons AL. Effect of air abrasion and tine desensitization induced by prophylactic 765–776. thermocycling on resin adaptation and and air-polishing procedures: an in vitro 50. Chen C, Niu LN, Xie H, et al. Bonding of shear bond strength to dentin for an dentine permeability and confocal micros- universal adhesives to dentine – old wine in etch-and-rinse and self-etch resin adhesive. copy study. Dent Mater 2010;38:411–422. new bottles? J Dent 2015;43:525–536. Dent Mater J 2012;31:180–188.

The International Journal of Esthetic Dentistry | Volume 15 | Number 1 | Spring 2020 | 41 CLINICAL RESEARCH

63. Hannig M, Femerling T. Influence of 69. Zimmerli B, De Munck J, Lussi A, tion of resins in dentin cavities. J Dent Res air-abrasion treatment on the interfacial Lambrechts P, Van Meerbeek B. Long- 1986;65:1319–1321. bond between composite and dentin. term bonding to eroded dentin requires 75. Villarroel M, Fahl N, De Sousa AM, Oper Dent 1998;23:258–265. superficial bur preparation. Clin Oral Investig De Oliveira OB Jr. Direct esthetic restor- 64. Manhart J, Mehl A, Schroeter R, Obster 2012;16:1451–1461. ations based on translucency and opacity B, Hickel R. Bond strength of composite to 70. Kubo S, Yokota H, Yokota H, Hayashi Y. of composite resins. J Esthet Restor Dent dentin treated by air abrasion. Oper Dent Challenges to the clinical placement and 2011;23:73–87. 1999;24:223–232. evaluation of adhesively-bonded, cervi- 76. Fahl N Jr. Direct-Indirect class V res- 65. D‘Amario M, Piccioni C, Di Carlo S, cal composite restorations. Dent Mater torations: a novel approach for treating De Angelis F, Caruso S, Capogreco M. 2013;29:10–27. noncarious cervical lesions. J Esthet Restor Effect of airborne particle air abrasion on 71. Peumans M, De Munck J, Van Landuyt Dent 2015;27:267–284. microtensile bond strength of total-etch KL, Poitevin A, Lambrechts P, Van Meerbeek 77. Ritter AV, Fahl N Jr, Vargas M, Maia RR. adhesives to human dentin. Biomed Res Int B. A 13-year clinical evaluation of two three- The direct-indirect technique for composite 2017;2017:2432536. step etch-and-rinse adhesives in non-car- restorations revisited. Compend Contin 66. Sutil BGDS, Susin AH. Dentin pre- ious class-V lesions. Clin Oral Investig Educ Dent 2017;38:e9–e12. treatment and adhesive temperature as 2012;16:129–137. 78. Kim JH, Cho J, Lee Y, Cho BH. The effecting factors on bond strength of a 72. Szesz A, Parreiras S, Martini E, Reis A, survival of Class V composite restorations universal adhesive system. J Appl Oral Sci Loguercio A. Effect of flowable com- and analysis of marginal discoloration. Oper 2017;25:533–540. posites on the clinical performance of Dent 2017;42:E93–E101. 67. Chaves P, Giannini M, Ambrosano GM. non-carious cervical lesions: a system- 79. Bignozzi I, Littarru C, Crea A, Vittorini Influence of smear layer pretreatments atic review and meta-analysis. J Dent Orgeas G, Landi L. Surgical treatment op- on bond strength to dentin. J Adhes Dent 2017;65:11–21. tions for grafting areas of gingival recession 2002;4:191–196. 73. Correia AMO, Tribst JPM, Matos FS, Platt association with cervical lesions: a review. 68. Van Meerbeek B, De Munck J, Mattar JA, Caneppele TMF, Borges ALS. Polymer- J Esthet Restor Dent 2013;25:371–382. D, Van Landuyt K, Lambrechts P. Microten- ization shrinkage stresses in different re- 80. Zucchelli G, Gori G, Mele M, et al. sile bond strengths of an etch&rinse and storative techniques for non-carious cervical Non-carious cervical lesions associated self-etch adhesive to enamel and dentin as lesions. J Dent 2018;76:68–74. with gingival recessions: a decision-making a function of surface treatment. Oper Dent 74. Hansen EK. Effect of cavity depth and process. J Periodontol 2011;82:1713–1724. 2003;28:647–660. application technique on marginal adapta-

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