Treatment Prognosis of Restored Teeth with Crown Lengthening vs. Deep Margin Elevation: A Systematic Review

Role of periodontal treatment in pregnancy gingivitis and adverse outcomes: a systematic review and meta-analysis

BACKGROUND

Pregnancy gingivitis is a common oral health issue that affects both maternal and fetal health. This study aims to evaluate the effectiveness of periodontal treatment in preventing pregnancy gingivitis, preterm birth, and low birth weight through a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. A comprehensive literature search was performed across CINAHL, Scopus, Cochrane, and PubMed/Medline databases from 2000 to the present. Study selection and data extraction were independently carried out by two reviewers. Statistical analyses, including heterogeneity tests, sensitivity analysis, and publication bias assessment, were conducted using RevMan 5.4 and R software.

RESULTS

A total of 13 studies were included. The meta-analysis indicated that periodontal treatment might have a potential effect on preventing pregnancy gingivitis, but this was not statistically significant (OR = 0.85, 95% CI [0.68, 1.06], I2 = 51%). Subgroup analysis revealed that periodontal treatment significantly reduced the rates of preterm birth and low birth weight in lower-quality studies, but no significant effects were observed in higher-quality studies. Sensitivity analysis and publication bias tests confirmed the stability and reliability of the results.

CONCLUSION

While lower-quality studies suggest that periodontal treatment may positively impact pregnancy gingivitis, preterm birth, and low birth weight, these effects were not supported by higher-quality evidence. Further well-designed RCTs are needed to confirm these findings and ensure their reliability. Periodontal treatment could potentially be considered as part of prenatal care to improve maternal oral health and pregnancy outcomes.

Digital resources for surgical and restorative treatment of excessive gingival display in one session

OBJECTIVE

This article aims to showcase the implementation of a digital workflow in addressing a case of multifactorial excessive gingival display in a patient with high esthetic demands, incorporating both surgical and restorative interventions in a single session.

CLINICAL CONSIDERATIONS

A 28-year-old female patient presented with excessive gingival display, attributed to a combination of short teeth due to altered passive eruption, lip hyperactivity, and a sub-nasal depression that lodged the upper lip during spontaneous smiling. The multidisciplinary treatment strategy encompassed surgical crown lengthening, the placement of a biovolume in the maxillary concavity, and the rehabilitation of the six anterior teeth with direct composite resin, all done in a single session. Smilecloud Biometrics was used to digitally plan the smile, and the final wax-up/mock-up was approved by the patient prior to any irreversible procedure. A digital planning center (GuiderLab) enabled the materialization of the virtual planning and the printing of the periodontal surgical guide, the biovolume, and the resin layering guides for the restorative technique.

CONCLUSIONS

Adopting a digital workflow in multidisciplinary cases with excessive gingival display leads to predictable and more expedited outcomes, ensuring a favorable result between soft and hard tissues.

CLINICAL SIGNIFICANCE

Excessive gingival display is a condition with multifactorial etiologies, including dentoalveolar, periodontal, skeletal, or muscular origins, or a combination of these factors. The diagnoses of altered passive eruption and a hypermobile upper lip are common in daily clinical practice and can be successfully managed through surgical crown lengthening and filling of the maxillary concavity, respectively. To achieve the desired outcome, restorative procedures often complement these surgical interventions.

Impact of dental operative microscopes on precision in minimally invasive dental restoration procedures

OBJECTIVE

To evaluate the effect of dental operative microscopes on precision in minimally invasive dental restoration procedures.

METHODS

This retrospective analysis included patients who underwent minimally invasive dental restoration procedure at Nanjing Stomatological Hospital from March 2018 to December 2019. Patients were categorized into two groups, an observation group treated with microscope-guided provisional restorations, and a control group treated using conventional methods. Clinical indices, including implant survival rates over five years, were compared between the groups. Multivariate analysis was employed to identify independent risk factors for implant failure.

RESULTS

After treatment the observation group exhibited significantly lower labial vertical marginal discrepancies and absolute marginal discrepancies, as well as improved labial gingival indices and periodontal probing depths compared to the control group (all P<0.001). Additionally, the observation group scored significantly higher in efficiency, accuracy, and overall quality of tooth preparation (all P<0.001). Clinicians using microscopes demonstrated significantly lower mean Rapid Upper Limb Assessment scores, indicating reduced ergonomic strain (P<0.001). Higher age, worn tooth defects, poor oral hygiene, and non-use of a microscope were identified as independent risk factors for implant failure at the five-year mark.

CONCLUSION

Dental operative microscopes significantly enhance the precision, efficiency, and ergonomic comfort in minimally invasive dental restorations for both clinicians and patients. Widespread adoption of this technology is strongly recommended.

Deep margin elevation in restorative dentistry: A scoping review

OBJECTIVES

Deep margin elevation (DME) is a restorative approach offering the possibility of performing stepwise elevation of deep proximal cavities to create more favourable margins for direct or indirect restorations. The objectives of this scoping review were to explore what is known or unknown about DME by describing a wide ranging evidence base including peer reviewed literature and non-traditionally published information on the web.

DATA

Data were extracted from the included evidence in order to describe the following: the extent and nature of the evidence base; the situations which are appropriate for DME; the materials and techniques which are used; the outcomes which have been measured in empirical studies; the risks which have been reported; and the findings which have been reported in studies which compared DME to surgical crown lengthening.

SOURCES

This scoping review included a wide range of published evidence and extensive web searching for grey literature, including CPD, training and multimedia information.

STUDY SELECTION

The findings revealed a range of published literature as well as freely available, online information advising practitioners about DME. Most empirical evidence was based on in vitro studies, and there were few clinical studies comparing DME to crown lengthening. Online information included recent, multimedia sources.

CONCLUSIONS

DME is a technique that can be used with motivated patients with good oral hygiene if rubber dam isolation is achieved, if there is no invasion of the connective tissue space, and if a strict restorative protocol is adhered to.

CLINICAL SIGNIFICANCE

With phasing out of amalgam and adhesive dentistry increasing in popularity, DME addresses multiple clinical problems associated with sub-gingival margins prior to restoration.

Effect of Deep Margin Elevation on the Pulpal and Periodontal Health of Teeth: A Systematic Review

OBJECTIVE

To systematically evaluate the clinical performance of deep margin elevation (DME) technique in terms of pulpal and periodontal health of teeth.

METHODS AND MATERIALS

An exploratory search was performed in PubMed, Scopus, Embase, Web of Science, and Google Scholar up to September 2023 by two authors independently. This systematic review was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Systematic Reviews (PRISMA-SR) and registered with PROSPERO-CRD42022382082. A custom-designed spreadsheet was used to extract the data. The quality of each study was evaluated by means of the Joanna Briggs Institute (JBI) risk of bias (ROB) tool specific for each study design.

RESULTS

A total of 5363 articles was obtained through an electronic database search, the grey literature, and a hand search. 2814 duplicates were removed, and an additional 2535 articles were also removed, as they did not meet the eligibility criteria. Following the screening of titles and abstracts, 16 articles were selected for full text reading, from which 10 articles were included for final qualitative analysis. DME was predominantly done with resin-based composite or glass ionomer cement (GIC). Parameters like periodontal pocket depth and bleeding on probing were within normal limits in all teeth with DME. Only one study checked the histological outcome and concluded that DME had no negative effect on the periodontium. Most of the studies used indirect restoration (composite/lithium disilicate/Emax) over the DME layer. The follow-up period ranged between 6 months and 12 years.

CONCLUSION

The level of evidence of this review is low, but DME was successful in all teeth, without any deleterious effect on pulp and periodontium.

Soft Tissue Retraction Maneuver in Cone Beam Computed Tomography Prior to Crown-Lengthening Procedure-A Technical Note

Background: An accurate determination of the biological width and the relationship of the cemento-enamel junction with the border of the alveolar bone is crucial during a clinical crown-lengthening (CCL) procedure. The aim of this study was to present a technical note about the retraction techniques in cone beam computed tomography (CBCT) prior to CCL, highlighting the significant enhancement in procedural accuracy and predictability that these techniques offer. Methods: Clinical and radiological examinations should be performed before a CCL procedure. It is necessary to determine the length of the tooth crowns, the periodontal pockets' depth, and the phenotype of the gingiva. The ideal CBCT examination should be performed with soft tissue retraction. This can be achieved using retractors or cotton rolls. Results: Retraction of the lips, cheeks, and tongue allows one to assess the marginal gingiva, the cemento-enamel junction, and the alveolar bone. A detailed plan of the CCL procedure, which involves retraction, ensures both the aesthetic appeal and the achievement of a newly defined gingival zenith, enhancing the overall visual harmony. Conclusions: Compared with conventional radiographic imaging, the soft tissue retraction maneuver in CBCT prior to CCL surgery offers an effective approach to the evaluation and diagnosis of soft and hard tissue. This is because of the detailed planning of the aesthetic CCL procedure. Such an approach leads to superior aesthetic outcomes in dentistry, contributing to the advancement of aesthetic dentistry through a harmonious blend of art and science.

Treatment planning algorithm for patients with a terminal dentition

This article discusses the variables that affect the diagnostic process in patients with a compromised dentition and addresses the clinical decision of whether to extract or maintain teeth. A decision tree algorithm is proposed to guide clinicians in planning complete arch rehabilitations.

Effect of cervical margin relocation on marginal adaptation and microleakage of indirect ceramic restorations

PURPOSE

This study evaluated the effect of cervical margin relocation (CMR) with two different materials and contamination with hemostatic agents on the margin adaptation and microleakage of ceramic restorations.

MATERIALS AND METHODS

Mesial-occlusal-distal cavities were prepared in 60 human first molars and distributed to 3 groups (n = 20) according to the margin relocation procedure. The groups were: group F; flowable composite applied in two 2 mm increments, group B; bulk-fill flowable composite applied as a bulk increment of 4 mm thickness and group C (control); no CMR was done. Each group was subdivided into two subgroups (subgroup N; no hemostatic agent applied and subgroup H; hemostatic agent was applied). In all groups, ceramic inlays were prepared and cemented. The samples were subjected to thermocycling (10,000 cycles). The adaptation of the cervical margin was evaluated with scanning electron microscopy (200×). Samples were then assessed for microleakage analysis with the dye penetration method. Marginal adaptation data were normally distributed and analyzed using two-way ANOVA followed by Tukey's post hoc test. Ordinal microleakage score data were analyzed using cumulative link models followed by the analysis of deviance using Wald chi-square tests.

RESULTS

Both CMR and contamination with a hemostatic agent had significant effects on the margin adaptation of the cervical margin. Group C showed the highest adaptation with no significant difference from group F. The lowest adaptation was revealed in group B with a significant difference from group C. Subgroup N (in all groups) showed a statistically higher adaptation than subgroup H. Regarding microleakage assessment, CMR had no significant effect but hemostatic agent application showed a significantly higher microleakage score for all groups.

CONCLUSIONS

Both the CMR procedure and contamination with AlCl3 hemostatic agent had a negative effect on marginal adaptation. For microleakage assessment, only contamination with hemostatic agent negatively affected the microleakage with no effect on the margin relocation procedure.

Dental and periodontal dimensions stability after esthetic clinical crown lengthening surgery: a 12-month clinical study

OBJECTIVES

To evaluate the stability of periodontal tissues 3 (T3), 6 (T6), and 12 (T12) months after esthetic crown lengthening (ACL) and the possible correlations between changes in those structures.

MATERIALS AND METHODS

Twenty individuals were evaluated through clinical assessment, photography, and tomography. Measurements included gingival margin (GM), clinical crown length (CCL), interdental papilla height (PH) and width (PW), gingival thickness (GT), bone thickness (BT), probing depth (PD), distance between alveolar crest and GM, distance between alveolar crest and cementoenamel junction. Nonparametric and correlation statistics were performed (p < 0.05).

RESULTS

CCL at T0 was 7.42 ± 0.70 mm and increased to 9.48 ± 0.49 mm immediately after ACL, but it decreased to 8.93 ± 0.65 mm at T12. PD decreased 0.60 mm from T0 to T6, and it increased 0.39 mm from T6 to T12. BT decreased 0.20 mm, while GT increased 0.29 mm from T0 to T12. Both PW and PH showed enlargement in T12. A positive moderate correlation was found between CCL/T0 and CCL/T12, GT/T0 and AC-GM/T12, BT/T0 and GT/T12. A few negative moderate correlations were PD/T0 and CCL/T12, PD/T0 and PH/T0, PD/T0 and BT/T12.

CONCLUSIONS

ACL procedure was effective. Although some rebound occurred, that was not clinically important. PD tended to reestablish its original length, partially due to a migration of GM during the healing period. Besides, a thickening of supracrestal soft tissues was observed.

CLINICAL RELEVANCE

The present study centers on the factors influencing the stability of periodontal tissues after esthetic crown lengthening, underscoring the procedure's influence on esthetics and biology and the need for careful treatment planning.

Biological evaluation of indirect restorations in endodontically treated posterior teeth with deeply located proximal margins following deep margin elevation versus surgical crown lengthening: a randomized controlled trial

OBJECTIVE

The current clinical trial was conducted to evaluate the effect of proximal indirect restorations in endodontically treated posterior teeth with deeply located margins following deep margin elevation compared to surgical crown lengthening.

MATERIAL AND METHODS

Deep proximal cavities in endodontically treated posterior teeth were randomly assigned into two groups; deep margin elevation (DME) or crown lengthening (CL). The clinical attachment level (CAL), probing depth (PD), bleeding on probing (BOP), crestal bone level (CBL), and secondary caries were evaluated at the baseline, 1, 3, 6, 9, and 12 months.

RESULTS

A total of 20 proximal cavities were included in the study; there was no significant difference between the two groups regarding mean CAL values at the baseline and 1 month, while there was a significant difference between the two groups in all other periods. Regarding the PD, there was no statistical significance between the two groups except at 9 and 12 months, where CL showed higher mean PD values than DME. There was no statistically significant difference in BOP or CBL between the two groups.

CONCLUSIONS

DME and CL are considered clinically successful with favorable biologic responses.

CLINICAL RELEVANCE

The deep margin elevation approach could provide a more conservative solution when relocating deeply seated cervical margins in a more coronal position. DME reduced the number of visits and time needed for the restoration of endodontically treated teeth. Surgical crown lengthening remains a gold standard procedure in the re-establishment of the supracrestal tissue attachment, especially in cases where cervical margins are beyond the elevation capacity.

Relationship between Deep Marginal Elevation and Periodontal Parameters: A Systematic Review

Background and Objectives: This review focuses on reviewing studies from the literature regarding the effects of deep margin elevation on the surrounding periodontium. Materials and Methods: A review of the literature was carried out using the following online databases: Embase, The Cochrane Library, MEDLINE-PubMed and Google Scholar. Our search was limited to articles from 2010 to 2023. The search terms consisted of keywords and MeSH terms, which were 'deep margin elevation', 'coronal margin relocation', 'periodontium' and 'periodontal tissues'. The literature was searched thoroughly by two reviewers. Initially, the titles of the articles were extracted. After removing irrelevant and duplicate articles, abstracts were assessed for relevant articles. Finally, the reviewers analyzed full-text articles. Results: A total of twelve articles, including one randomized clinical trial, three systematic reviews, two prospective cohort, three case series, one a clinical study, one pilot study and one a retrospective study, were selected and analyzed. Conclusions: The review suggests potential benefits of Deep Margin Elevation (DME) over surgical crown lengthening due to reduced invasiveness, yet conclusive effects on periodontal tissue remain unclear, warranting further studies on clinical parameters and inflammatory biomarkers.

Different Designs of Deep Marginal Elevation and Its Influence on Fracture Resistance of Teeth with Monolith Zirconia Full-Contour Crowns

Background and objectives: Even with the demand for high esthetics, the strength of the material for esthetic applications continues to be important. In this study, monolith zirconia (MZi) crowns fabricated using CAD/CAM were tested for fracture resistance (FR) in teeth with class II cavity designs with varying proximal depths, restored through a deep marginal elevation technique (DME). Materials and Methods: Forty premolars were randomly divided into four groups of ten teeth. In Group A, tooth preparation was conducted and MZi crowns were fabricated. In Group B, mesio-occluso-distal (MOD) cavities were prepared and restored with microhybrid composites before tooth preparation and the fabrication of MZi crowns. In Groups C and D, MOD cavities were prepared, differentiated by the depth of the gingival seat, 2 mm and 4 mm below the cemento-enamel junction (CEJ). Microhybrid composite resin was used for DME on the CEJ and for the restoration of the MOD cavities; beforehand, tooth preparations were conducted and MZi crowns were and cemented using resin cement. The maximum load to fracture (in newtons (N)) and FR (in megapascals (MPa)) were measured using the universal testing machine. Results: The average scores indicate a gradual decrease in the load required to fracture the samples from Groups A to D, with mean values of 3415.61 N, 2494.11 N, 2108.25 N and 1891.95 N, respectively. ANOVA revealed highly significant differences between the groups. Multiple group comparisons using the Tukey HSD post hoc test revealed that Group D had greater DME depths and showed significant differences compared with Group B. Conclusions: FR in teeth decreased when more tooth structure was involved, even with MZi crowns. However, DME up to 2 mm below the CEJ did not negatively influence the FR. Strengthening the DME-treated teeth with MZi crowns could be a reasonable clinical option, as the force required to fracture the samples far exceeded the maximum recorded biting force for posterior teeth.

Deep margin elevation-Present status and future directions

OBJECTIVE

Deep margin elevation (DME) is a treatment approach to relocate the cervical margin of teeth with subgingival defects to a supragingival position with a direct restoration to facilitate rubber dam isolation, impression taking, and bonding of indirect restorations. This article provides an overview of the current scientific evidence on DME and future directions for research.

OVERVIEW

The review included 38 studies on DME, most conducted in vitro. These studies indicate that DME has no detrimental effect on the fracture resistance of restored teeth. Evidence on the impact of DME on marginal quality is conflicting, but most in vitro studies observed no negative effect. Clinical studies, most comprising small patient cohorts, demonstrated favorable restorative outcomes and suggest that DME restorations made with scrupulous care are compatible with periodontal health. Bleeding on probing may occur more frequently at sites with DME, though evidence on this is not unequivocal.

CONCLUSIONS

Current evidence, based largely on laboratory studies and limited clinical data, supports DME as a viable approach to restore teeth with localized subgingival defects. However, further clinical studies with long-term follow-ups are required to provide corroborative evidence.

CLINICAL SIGNIFICANCE

Current evidence suggests that DME is a viable approach to restore teeth with localized subgingival defects as a possible alternative to surgical crown lengthening. Proper working field isolation, meticulous care in the bonding and buildup procedure, and biofilm removal through patient-performed oral hygiene and professional maintenance care are crucial. As scant clinical trial-based evidence is available today, further research is needed to evaluate the long-term performance of DME restorations and their impact on periodontal health.

Deep Margin Elevation: Current Concepts and Clinical Considerations: A Review

Dietschi and Spreafico first proposed deep margin elevation (DME) in 1998 to address the multiple clinical problems associated with sub-gingival margins, where sub-gingival margins will be repositioned coronally using composite resin restorations. Given that dentistry is directing towards conservatism, its use is currently trending. Materials and Methods: a search was performed through PubMed, Scopus, and Google Scholar search engines to obtain relevant articles with no time restriction. Results: With biological width taken into consideration, well-defined and polished sub-gingival restorations are compatible with periodontal health. Marginal integrity in the DME technique seems to be affected by the type of adhesive, restoration, and incremental layering of the restoration. Regarding fracture resistance, DME has no significant effects. Conclusion: The DME technique seems to be a minimally invasive alternative to surgical crown lengthening (SCL) and orthodontic extrusion (OE) with respect to biological width. Well-controlled clinical trials are limited in this field; further long-term follow-up studies emphasizing the periodontal outcomes and prevention of complications are needed.

Deep Margin Elevation: A Literature Review

A conservative approach for restoring deep proximal lesions is to apply an increment of composite resin over the preexisting cervical margin to relocate it coronally, the so-called “deep margin elevation” (DME). A literature search for research articles referring to DME published from January 1998 until November 2021 was conducted using MEDLINE (PubMed), Ovid, Scopus, Cochrane Library and Semantic Scholar databases applying preset inclusion and exclusion criteria. Elevation material and adhesive system employed for luting seem to be significant factors concerning the marginal adaptation of the restoration. This technique does not affect bond strength, fatigue behavior, fracture resistance, failure pattern or repairability. DME and subgingival restorations are compatible with periodontal health, given that they are well-polished and refined. The available literature is limited mainly to in vitro studies. Therefore, randomized clinical trials with extended follow-up periods are necessary to clarify all aspects of the technique and ascertain its validity in clinical practice. For the time being, DME should be applied with caution respecting three criteria: capability of field isolation, the perfect seal of the cervical margin provided by the matrix, and no invasion of the connective compartment of biological width.