Received: 9 April 2022 Accepted: 30 July 2022

DOI: 10.1002/cap.10222

C A S E S T U DY

Vestibular tunnel approach in restoring non-carious cervical

lesion gingival recessions with combination of bioceramics and
collagen matrix: A case report with a 1-year follow-up

Kai-Chiao Joe Chang1 John H. Mumford2 Alex Long3 Vinh H. Ton4

1
Department of Periodontics, Arizona School of
Dentistry and Oral Health, A.T. Still University,
Mesa, Arizona, USA
2
Private Practice, CAPT (Ret) United States Navy,
Boise, Idaho, USA
3
Department of Periodontics, Naval
Postgraduate Dental School, Bethesda,
Maryland, USA
4
Division of Periodontics, Naval Dental
Center/1st Dental Battalion, Camp Pendleton,
California, USA
Correspondence
Kai-Chiao Joe Chang, Department of
Periodontics, Arizona School of Dentistry and
Oral Health, A.T. Still University, 5855 E. Still
Circle, Mesa, AZ 85206, USA.
Email: joechang@atsu.edu
Abstract
Introduction: Non-carious cervical lesions (NCCLs) can compromise the integrity
to both hard and soft tissues of teeth. This case report introduces a novel inter-
disciplinary technique by utilizing bioceramics-based cement (BBC) and porcine
collagen matrix (CM) to reconstruct the dentogingival complex where enamel,
dentin, and soft tissues were involved.
Case presentation: A 38-year-old healthy male was referred to the periodontics
department for gingival recessions teeth #27–29 and a deep (NCCL) on the facial
(F) #28 involving the loss of the cementoenamel junction (CEJ). The F #28 was
restored with BBC according to manufacturing instructions. Soft tissues of #27–29
were simultaneously augmented with two CM strips via a coronally advanced tun-
nel utilizing suspended sutures. At the 6-month follow-up, approximately 100%
root coverages were obtained for #27 and 29. The F #28 gingival tissue stabi-
lized at the anticipated level of maximum root coverage (MRC), 1 mm apical to
the coronally displaced CEJ. The exposed layer of BBC, F #28, was veneered with
resin-modified glass ionomer to re-establish the original position of the CEJ. At
the one-year follow-up visit root coverage for #28 remained stable and probing
depths remained unchanged at 2 mm F #27–29. A sectional cone beam com-
puted tomography scan illustrated the BBC restoration remained intact and well
adapted.
Conclusion: The 12-month follow-up illustrated that the BBC may be a viable
restorable material while performing simultaneous gingival grafting with CM in
deep NCCLs with gingival recessions.

KEYWORDS
bioceramics, collagen matrix, gingival recession, non-carious cervical lesion

Key points
Why is this case new information?
∙ A novel approach treating the deep non-carious cervical lesion with BBC and
CM.
What are the keys to successful management of this case?
∙ The BBC placement needs to be flat.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Clinical Advances in Periodontics published by Wiley Periodicals LLC on behalf of American Academy of Periodontology.

56 wileyonlinelibrary.com/journal/cap Clin Adv Periodontics. 2023;13:56–61.


CLINICAL ADVANCES IN PERIODONTICS
∙ Secure the surgical site with non-resorbable suspensory sutures fixed by
flowable composite.
What are the primary limitations to success in this case?
∙ The primary limitation to success is the blood moisture control which may limit
the placement of collagen matrix strips via the portal entry.
BACKGROUND
A non-carious cervical lesion (NCCL) often presents with a
loss of structural integrity as well as the esthetics around the
dentogingival complex (DGC), which may require interdis-
ciplinary treatment collaboration.1
Restoring type 3 and type 4 NCCLs can be challeng-
ing because the cementoenamel junction (CEJ) can be
displaced coronally due to the loss of both enamel and
dentin.1 Therefore, the outcome of mucogingival surgery
may appear to be less than anticipated since the soft tis-
sue margin will be apical to the coronal aspect of the
displaced clinical CEJ, which was not addressed by Miller’s
classification.1,2,3 To accurately predict the maximum root
coverage (MRC) on type 3 NCCLs, Zuccelli et al. suggested a
calculation that integrated the facial aspect of the CEJ to the
ideal height of the interdental papilla with an evaluation of
the lesion depth and extension.1,4
Although resin-modified glass ionomer cement (RMGI)
has been recommended to restore NCCL, improper isola-
tion can affect marginal access and adhesion for subgingi-
val restorations.5,6 In contrast, bioceramics-based cements
(BBCs) have been widely used in endodontics for seal-
ing subgingival root dentin and possess hydrophilic and
antimicrobial properties, which improve the marginal seal
and caries prevention, with osteoinductive and regenera-
tive potentials.7,8 These properties make BBCs an attractive
alternative material for restoring NCCLs.
Several gingival grafting techniques on NCCLs have
been studied involving autogenous grafts, allografts, or
xenografts.9–11 While porcine collagen matrix (CM) has
been known for soft-tissue enhancement and root cover-
age, no studies have utilized CM to cover BBC in managing
NCCL defects. This report introduces a novel approach
for the repair of a type 3 NCCL associated with Miller
class I recession utilizing BBC and CM strips inserted via
subepithelial tunnel access and monitors the postsurgical
mucogingival complex stability over a 12-month period.
CLINICAL PRESENTATION
A healthy 38-year-old male, American Society of Anesthe-
siologists (ASA) 1, presented to the periodontics clinic for
revaluation of NCCLs with recession on teeth #27–29. The
periodontium was healthy, presented with adequate ker-
atinized tissue, and probing depths (PDs) ranged from 2
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57
to 4 mm (mid-facial PD was 2 mm for #27–29). Diagnoses
included Miller type I recession #27–29 with type I NCCL
for #27 and 29, and a type 3 NCCL for #28 extending 3 mm
in depth (Figures 1A–C and 2 and Table 1). Surgical treat-
ment options were discussed as well as restorative options
for #28 as the anticipated MRC was calculated to be 1 mm
apical to the most coronal aspect of the NCCL. A combined
restorative approach was presented to take advantage of
the subgingival benefits of BBC and sandwich the antici-
pated 1 mm supragingival exposure with a more esthetic
RMGI restoration following surgical healing. The patient
signed written informed consent of gingival augmentation
of #27–29 and restoration of #28.
CASE MANAGEMENT
After local anesthesia, teeth #27–29 were scaled and
root planed and treated with ethylenediaminetetraacetic
acid| (24%). A gingival retraction cord was placed around
the free gingival margin of #28 and restored with BBC¶
(Figure 3). Following the restoration of #28, a tunneling
surgical approach was accomplished for the placement of
CM# (Figure 4A–C).12 The portal was closed with inter-
rupted resorbable chromic gut sutures.** The gingival tis-
sues of #27–28 were advanced coronally with suspensory
polypropylene sutures,†† which were fixed with flowable
composite. A horizontal mattress polytetrafluoroethylene
suture‡‡ was placed from #27–29 to stabilize the CM#
(Figure 5). Post-operative medications included ibupro-
fen§§ (800 mg, tid, prn) and 0.12% chlorhexidine rinse|| (15
cc, rinse bid, for 2 weeks).
CLINICAL OUTCOMES
Post-operative appointments were accomplished at 2
weeks, 6 weeks, 6 months, and 12 months. Normal heal-
ing was observed at the 2-week visit and all sutures were
|
PrefGel, Straumann Holding, Basel, Switzerland.
¶
Endosequence BC RRM-Fast Set Putty, Brasseler, Savannah, GA, USA.
#
Mucograft, Geistlich Pharma North America, Princeton, NJ, USA.
**
Chromic gut suture, Ethicon Johnson & Johnson, Somerville, NJ, USA.
††
Polypropylene, Ethicon Johnson & Johnson, Somerville, NJ, USA.
‡‡
CV-5 ePTFE Nonresorbable Monofilament, W.L. GORE & Associates, Inc., Flagstaff,
AZ, USA.
§§
Ibuprofen tablet, Pharmacia & Upjohn, New York, NY, USA.
||
Peridex, 3M ESPE Dental Products, St. Paul, MN, USA.
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58 CHANG ET AL.

F I G U R E 1 Pre-operative. (A) Buccal view of teeth #27–29 at the initial consultation (2018). (B) Bitewing X-ray taken at the time of consultation
(2018). (C) Depth of non-carious cervical lesion #28.

TA B L E 1 Clinical measurements of cervical lesion height (CLH), width (CLW), depth (CLD), and clinical attachment loss (CAL) at the baseline (2018)
Tooth # CLH (mm) CLW (mm) CLD (mm) CAL-F (mm) PD-F (mm) Rec-F (mm)
27 3 4 1 5 2 3
28 4 4 3 6 2 4
29 2 3.5 1 4 2 2
Abbreviations: F, facial; PD, probing depth; Rec, Recession.

removed (Figure 6). At the 6-week post-operative visit, the

F I G U R E 2 An illustration of non-carious cervical lesion defect
assessments. CLD, cervical lesion depth; CLH, cervical lesion height; CLW,
cervical lesion width.
gingival tissue around tooth #28 was firm and healthy
showing the anticipated MRC 1 mm apical to the enamel
margin (Figure 7). The soft-tissue level remained stable at
the anticipated MRC at the 6-month visit (1 mm below the
enamel margin). The exposed BBC was veneered with an
RMGI¶¶ to re-establish the contour and original level of the
CEJ of #28 (Figure 8). At the 1-year follow-up visit, gingi-
val levels showed no further signs of cervical wear around
the DGC (Figure 9). Clinical measurements were recorded
(Table 2). A sectional cone beam computed tomography
scan was performed to verify the post-BBC placement
(Figure 10A,B). The BBC appeared to be a compatible
medium with DGC and 1.5 mm above the alveolar crest.

DISCUSSION

In repairing NCCLs, determining the MRC is a preeminent

F I G U R E 3 The placement and contour of bioceramics-based cement
(BBC¶ ) tooth #28.
step in clinical management.4 Restoring the NCCL type 3
associated with Miller class I–III gingival recessions is more
complex when the defect is narrow and ≥1 mm in depth.1
In this case, the cervical lesion depth was 3 mm with the loss
of both enamel (crown) and root structures combined with
a Miller class I recession.
The BBC we used produced nanosphere particles that
channel into dentin tubules in a moist environment cre-
ating a strong mechanical bond and marginal stability to
dentin subgingivally. We anticipated supragingival expo-
sure of BBC and its esthetic and wear issues since MRC was
1 mm apical to the coronal aspect of the NCCL. The treat-
ment plan addressed this issue by sandwiching the BBC
¶¶
GC Fuji II, GC America, Alsip, IL, USA.
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CLINICAL ADVANCES IN PERIODONTICS 59

F I G U R E 4 Schematic illustration of surgical site #27–30. (A) Full thickness reflection around the gingival sulci from distofacial #26 to distobuccal #30
in addition to a full subperiosteal release from the vestibular entry. (B) Trimmed the porcine collagen matrix (CM# ) into two strips using surgical scissors.
(C) Illustrating placement of the CM# strips to cover the recession.

F I G U R E 5 Buccal view of site closure with suspensory†† and

horizontal mattress‡‡ sutures. F I G U R E 7 Six weeks post-operative visit—anticipated MRC 1 mm
apical to enamel margin #28.

with RMGI when restoring the original contour and level

of the CEJ. A recent review suggested that adding BBC
to resin-based restorative materials may promote reminer-
alization and improve the marginal seal.13 The RMGI and
BBC demonstrated a stable mechanical interphase at our
6-month follow-up visit.
While autogenous subepithelial connective tissue graft-
ing (SCTG) with coronally advanced flap (CAF) is considered
the gold standard,14 a systematic review and meta-analysis
found no significant difference in clinical attachment level
and keratinized tissue widths for the treatment of multiple
gingival recessions when comparing CM as an alternative to
FIGURE 6 The 2-week follow-up visit after suture removal. autogenous SCTG.15
 21630097, 2023, 1, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/cap.10222, Wiley Online Library on [23/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
60 CHANG ET AL.

TA B L E 2 Comparison of clinical parameters before therapy and at the 1-year follow-up

CAL-F (mm), PD-F (mm), Rec-F (mm), CAL-F (mm), PD-F (mm), Rec-F (mm),
Tooth # Baseline Baseline Baseline 1-Year Exam 1-Year xam 1-Year Exam
27. CM# 5 2 3 2 2 0
28. BBC¶ + RMGI¶¶ + CM‡ 6 2 4 2 2 0
29. CM‡ 4 2 2 2.5 2 0.5
Abbreviations: BBC, bioceramics-based cement; CAL, clinical attachment loss; CM, collagen matrix; F, facial; PD, probing depth; Rec, Recession; RMGI, resin-modified glass ionomer.

F I G U R E 8 The 6 months post-operative visit—re-established the

contour and the original level of the CEJ by veering the BBC with RMGI¶¶
#28.

Many surgical approaches utilized vestibular access to

enhance functional esthetics and vascularization without
donor tissue harvesting.12 Our surgical design resem-
bled the study by Schulze-Späte and Lee11 ; however, F I G U R E 9 One-year post-operative visit—stable dentogingival
we approached the case by placing two individual non- complex (DGC) without sign of inflammation.
crosslinked CM strips against the roots in an attempt to
gain gingival attachment and tissue thickness. The one-

F I G U R E 1 0 A cross-sectional view (A) and buccal view (B) of cone beam computed tomography scan illustrating the bioceramics-based cement
(BBC¶ ) interphase stability.

CLINICAL ADVANCES IN PERIODONTICS
year follow-up confirmed the stable soft-tissue volume and
biocompatibility of the BBC without any adverse effects
along interphase junctions (cementum–BBC, BBC–dentin,
and RMGI–BBC).
CONCLUSION
This case demonstrated that BBC in conjunction with CM
and CAF could be an alternative treatment option for type
3 NCCL defects.
ACKNOWLEDGMENTS
The authors do not have any financial interests, either
directly or indirectly, in the products or information
included in the paper.
CONFLIC T OF INTEREST
The authors report no conflicts of interest related to this
case study.
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How to cite this article: Chang K-CJ, Mumford JH,
Long A, Ton VH. Vestibular tunnel approach in
restoring non-carious cervical lesion gingival
recessions with combination of bioceramics and
collagen matrix: A case report with a 1-year
follow-up. Clin Adv Periodontics. 2023;13:56–61.
https://doi.org/10.1002/cap.10222