Clinical Performance of Posterior Indirect Resin Composite Restorations with the Proximal Box Elevation Technique: A Prospective Clinical Trial up to 3 Years

PURPOSE

The study evaluated the clinical performance of partial indirect resin composite (PIRC) restorations with "proximal box elevation" (PBE) placed in molars.

MATERIALS AND METHODS

Sixty-three patients received 80 posterior PIRC (SR Nexco, Ivoclar Vivadent) restorations. Large posterior defects with cuspal loss and deep cervical margins were included in the study. PBE was performed prior to preparation and impression making. Two independent observers evaluated the restorations using the FDI criteria (scores 1-5) for esthetic, functional, and biological properties. Patients were recalled at 6 months and 1, 2, and 3 years. Overall success rates were calculated (Kaplan-Meier analysis) and compared (log-rank tests) according to baseline variables. The impact of the baseline variables on the failure of the restorations was analyzed (multiple proportional Cox regression).

RESULTS

Seventy-nine (98.7%), 69 (88.4%), 66 (92.9%), 44 (86.2%) and 45 (91.8%) PIRCs completed their follow up at baseline, 6 months, and 1, 2 and 3 years, respectively. In total, 10 failures were observed: 5 with partial loss, 4 with material chipping, and one with secondary caries, yielding an overall success rate of 87.5% and a survival rate of 93.8%, with a mean observation time of 26.5 ± 13.6 months.

CONCLUSIONS

PIRCs with PBE demonstrated a high survival rate and satisfactory esthetic properties. Failure was less likely for PIRC restorations with partial cuspal coverage (onlay) compared to full cuspal coverage (overlay).

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.

Retrospective Clinical Evaluation of Subgingival Composite Resin Restorations with Deep-Margin Elevation

PURPOSE

To evaluate the long-term clinical quality of subgingivally placed composite resin restorations and the inflammatory status of surrounding supracrestal gingival and periodontal tissues.

MATERIALS AND METHODS

Patients with at least one subgingival restoration with deep-margin elevation placed between 2010 and 2020 at Heidelberg University Hospital and Tübingen University Hospital were identified. A sound tooth was used as control. Intraoral examination including probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), gingival bleeding index (GBI), and plaque control record (PCR) was conducted. The clinical quality of the restorations was evaluated using the modified FDI criteria. For comparison between control and test teeth, a logistic mixed-effects model was used for GBI, PCR, and BOP, while a linear mixed-effects model was used for CAL. Multivariable linear and logistic regressions were used to examine the influence of smoking, age of restoration, number of decayed, missing and filled teeth, use of interdental brushes, and CAL.

RESULTS

Sixty-three patients were included in the study. The mean age of the restorations was 2.70 ± 1.90 years. There were no significant differences between test and control teeth with respect to inflammatory parameters BOP, GBI, and PCR. CAL was significantly higher in test teeth than in controls (p = 0.027). The regression models revealed that CAL has a significant influence on GBI (p = 0.008) and BOP (p < 0.001). A significantly increased GBI occurred especially on test teeth in patients who did not use interdental brushes daily (p = 0.010). The clinical quality of restorations was rated excellent or good in 70%, an no restoration was rated unacceptable.

CONCLUSION

No increased inflammation was observed on sites with subgingivally placed composite restorations over an observation period of approximately 3 years. Regular interdental brush use was associated with less gingival inflammation.

Assessment of knowledge, attitude, and practice regarding Deep Margin Elevation (DME) among dental practitioners in Riyadh, Saudi Arabia

Objectives:

To evaluate Knowledge, Attitude, and Practice (KAP) regarding deep margin elevation (DME) among dental practitioners in Riyadh city.

Materials and Methodology:

A cross-sectional study that comprised a total number of 535 dental practitioners: 255 (47.7%) were males and 280 (52.3%) females. A self-constructed 21 close-ended self-administered questionnaire was utilized in the study. The data were entered and analyzed by Chi-square test and descriptive analysis using Statistical Package for the Social Sciences (SPSS) software.

Results:

Although the majority of the respondents have heard about DME, only 30.4% have utilized this technique in their clinical practice by having general practitioners and specialists utilize this technique more often than consultants. Among the participants, 65.4% of them have agreed that adhesion by bonding to deep cervical dentin is predictable and related to the success of the final restoration.

Conclusion:

The knowledge level of DME among the study participants was adequate. The findings of this study revealed that the total number of dentists who utilize the technique in restoring large subgingival defects of posterior teeth with proximal caries is very minimal. Thus, it is recommended that dental practitioners have this technique introduced in their dental clinics as an alternative to surgical crown lengthening. Although years of experience and dentist rank may influence the clinical decision, in-depth factorial analysis with a greater sample size is necessary.

Effect of cervical margin relocation technique with composite resin on the marginal integrity of a ceramic onlay: a case report

Treatment of a large proximal carious lesion that extends below the cementoenamel junction is challenging. Large defects usually require replacement with indirect restorations (inlays, onlays, or crowns). However, when the gingival cavity margins are deep, procedures such as isolation of the operative field, proper cavity preparation, successful impression-making, and adhesive luting may be hindered unless soft gingival or hard bony tissues are removed to expose the cavity margin. The present case report describes the clinical application of a conservative cervical margin relocation technique for treating deep cavity margins. A patient presented with large distal carious lesions and necrotic pulps in both the maxillary and mandibular right first molars, which were diagnosed with symptomatic apical periodontitis. After root canal treatment of both teeth, the maxillary molar underwent a crown-lengthening surgical procedure and subsequent placement of a zirconia crown. In the mandibular molar, the cervical margin was relocated by placing a composite resin base at the proximal gingival cavity margins under meticulous isolation of the operative field. The tooth was restored with a composite core build-up and bonded ceramic onlay. The satisfactory outcome suggested a promising prognosis for the oral health of the patient.

Marginal sealing of relocated cervical margins of mesio-occluso-distal overlays

We investigated the effect of cervical marginal relocation (CMR) on marginal sealing with two different viscosity resin composites, before adhesive cementation of composite computer-aided design/computer-assisted manufacture mesio-occluso-distal (MOD) overlays. Standardized MOD cavities prepared in 39 human molars were randomly assigned to three groups. The proximal margins on the mesial side were located 1 mm below the cementoenamel junction. On the distal side of the tooth, the margins were located 1 mm above the cementoenamel junction. In Groups 1 and 2, mesial proximal boxes were elevated with a hybrid composite (GC Essentia MD) and a flowable composite (GC G-ænial Universal Flo), respectively. CMR was not performed in Group 3. The overlays were adhesively cemented, and interfacial leakage was quantified by scoring the depth of silver nitrate penetration along the adhesive interfaces. Leakage score at the dentin-CMR composite interface did not significantly differ between the two tested composites but was significantly lower for Group 3. In all groups, scores were significantly higher at the dentin interface than at the enamel interface. These results indicate that the performance of flowable and microhybrid resin composites, as indicated by marginal sealing ability, is comparable for CMR.