What is the recommended management for gingival recession from toothbrush abrasions with Non-Cariously Cervical Lesions (NCCLs) on all posteriors and canines, and what techniques can help with root coverage?

Management of Gingival Recession from Toothbrush Abrasions with NCCLs

The recommended management is a combined restorative-surgical approach: first restore the NCCLs with composite resin or resin-modified glass ionomer, then perform coronally advanced flap (CAF) with connective tissue graft (CTG) to achieve root coverage, which provides 70-92% coverage with superior long-term stability. 1

Initial Non-Surgical Management

Address the causative factors immediately to prevent progression:

• Modify toothbrushing technique to the Bass or modified Bass method using a soft toothbrush, replacing monthly 2
• Use mild fluoride-containing, non-foaming toothpaste and brush only twice daily (after meals and bedtime) 2
• Establish optimal plaque control and remove any overhanging subgingival restorations 3
• Implement behavior change interventions to eliminate traumatic brushing habits 3

Restorative Phase: NCCL Management

Restore all NCCLs prior to surgical intervention:

• Nanofilled composite resin (NCR) or resin-modified glass ionomer cement (RMGI) are the preferred materials, both achieving approximately 71% defect coverage when combined with CTG 4
• Giomer materials may be less effective (64% coverage) and should be avoided 4
• The restoration provides proper emergence profile and protects the exposed dentin during healing 5

Surgical Phase: Root Coverage Technique

Perform CAF with CTG as the gold standard approach:

Surgical Protocol 2, 1

• Prepare horizontal beveled incisions (±3mm length) mesial and distal to recession, at distance from papillae tips equal to recession depth plus 1mm 2
• Create beveled oblique, slightly divergent incisions extending to alveolar mucosa 2
• Elevate trapezoidal flap with split-full-split approach: split thickness for surgical papillae, full thickness at root exposure, split thickness for vertical incisions 2
• De-epithelialize papillae and complete optimal root planing 2
• Place CTG to achieve at least 1.5mm gingival thickness, which is critical for long-term stability 1
• Coronally advance flap to cover graft and suture with modified vertical mattress and interrupted sutures using 5-0 or 6-0 monofilament non-absorbable sutures 2

Alternative When CTG Contraindicated

If palatal harvesting is contraindicated or patient refuses donor site surgery:

• Use 3-4 layers of L-PRF membranes with CAF as alternative to CTG 2, 1
• Suture L-PRF membranes together with absorbable 6-0 sutures, place on receptor bed with face portion toward exposed root 2
• Avoid relying solely on growth factor approaches (rhPDGF-BB, soft tissue matrices) as they show significant reduction in coverage from 89.85% at 6 months to 74.10% at 5 years 1

Critical Success Factors

Ensure adequate gingival thickness and keratinized tissue:

• Minimum 1.46mm gingival thickness at 6 months is the main determinant of long-term stability 1
• At least 1.5mm keratinized tissue width prevents recession recurrence 1
• Sites with initial KTW ≥2mm show significantly higher mean root coverage and complete root coverage rates 6

Post-Operative Management

Strict protocol for optimal healing: 2, 1

• Restrict to soft food intake with no biting/chewing in treated area for 1 week 2, 1
• No mechanical cleaning of treated area for 1 week 2
• Rinse with 0.12% chlorhexidine twice daily for minimum 3 weeks (starting day 3) 2, 1
• Prescribe analgesics for post-operative pain management 2

Common Pitfalls to Avoid

Critical errors that compromise outcomes:

• Never proceed with CAF alone in thin phenotype cases - this results in long-term recession recurrence 1
• Do not perform surgery without first restoring NCCLs - the restoration is essential for proper emergence profile and predictable outcomes 4, 5
• Avoid insufficient graft thickness - failure to achieve 1.5mm thickness leads to significant recession over 5 years 1
• Do not use giomer materials for NCCL restoration as they show inferior results compared to composite or RMGI 4

Long-Term Outcomes

Expected results with proper technique:

• Autogenous CTG demonstrates 89.35% coverage at 5 years, superior to all alternative approaches 1
• Mean root coverage of 71-83% is achievable with combined restorative-surgical approach 4, 6
• Complete root coverage in 50% of cases when proper technique and patient selection criteria are met 6