CLINICAL RESEARCH

Clinical guidelines for posterior

restorations based on Coverage,
Adhesion, Resistance, Esthetics,
and Subgingival management
The CARES concept: Part III – subgingival
margins, “ferrule” design, and posts in severely
compromised teeth

Jorge André Cardoso, DMD

Porto University, Portugal
MClinDent and Postgraduate Tutor in Prosthodontics, Kings College London, UK
Private Practice, Espinho, Portugal

Pasquale Venuti, DMD

Naple Frederico II University (cum laude), Italy
Private Practice, Mirabela Eclano, Italy

Nuno Sousa Dias, DMD

Fernando Pessoa University, Portugal
Tel Aviv University, Israel
Private Practice, Porto (Portugal), Istanbul (Turkey), Antwerp (Belgium), and Madrid (Spain)

João Vinha Oliveira, DMD

ISCS-N University, Portugal
MAS & Assistant, Microinvasive Aesthetic Dentistry, University of Geneva, Switzerland
Private Practice, Neuchatel, Switzerland

Joel Bastos, DMD

Catholic University, Portugal
Private Practice, Paris, France

Ricardo Henriques, DMD

Porto University, Portugal
Private Practice, Feira, Portugal

Correspondence to: Dr Jorge André Cardoso

Ora Clinic, Rua 23, 344, 3C, 4500-142 Espinho, Portugal; Tel: +351 916121312; Email: jorge.andre@ora.pt

14 | The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024

 Cardoso et al

Abstract

Despite the clear advances regarding the restoration
of posterior teeth, especially with the minimally inva-
sive approach, there are still several topics where the
available scientific evidence does not provide clear an-
swers in terms of clinical decisions. The indications,
differences, and clinical protocols for partial adhesive
restorations (onlays, overlays, and endocrowns) and
resistance form restorations (full-contour resistive
crowns) were presented in Parts I and II of the present
article series based on Coverage of susceptible cusps,
Adhesion advantages and limitations, Resistance
forms to be implemented, Esthetic concerns, and
Subgingival management ­– the CARES concept. Now,
in Part III, the focus is on different approaches of man-
aging subgingival areas, gaining “ferrule” design, and
the role of posts on the restorability strategies of se-
verely compromised teeth.

 (Int J Esthet Dent 2024;19:14–33)

Keywords

adhesive dentistry, dental technology, periodontology, prosthodontics, restorative dentistry

Submitted: January 1, 2023; accepted: January 3, 2023

The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024 | 15

Clinical Research
Introduction
This three-part article series presents clinical
guidelines for practical decisions on differ-
ent types of posterior restorations based on
progressive degrees of tissue loss. Part I dis-
cussed the specific characteristics of poster-
ior teeth and detailed clinical decisions in
different types of partial adhesive resto-
rations. Part II detailed the indications and
treatment possibilities for full-contour resis-
tive crowns, particularly with vertical prepar-
ations. These proposed clinical decisions are
based on the amount of sound vertical walls
coronal to the equator of the tooth and their
relative presence throughout the whole
peri­phery (Fig 1). This final part of the article
series, Part III, focuses on the management
of compromised teeth that present a re-
storative challenge due to subgingival areas
or lack of a “ferrule” design – a minimal
amount of height and thickness of tooth
structure to which the restoration can en-
gage for an acceptable clinical prognosis.1
Managing subgingival margins
according to restoration type
Subgingival areas may be present for vari-
ous reasons. This is usually caused by caries
or fractures and less commonly by resorp-
tion processes and noncarious cervical le-
sions. For example, caries removal in the
interproximal area frequently results in a
horizontally prepared area. A fracture, how-
ever, normally causes a vertical or oblique
defect on the tooth structure. As long as the
extent of the lesions does not compromise
tooth viability (possibility of creating a “fer-
rule” design), these areas can be managed
successfully with different strategies.
The first important analysis to be made is
whether the restoration is adhesive or resis-
tive, based on the vertical height of the re-
maining walls per tooth periphery, as dis-
cussed in Part I of this article series (Fig 1).
16 | The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024
Once that is established, the next decision is
which strategy to use to manage subgingi-
val areas or gain “ferrule,” depending on the
depth of the lesion – supraosseous or in-
fraosseous.
The subgingival areas that appear in teeth
evaluated as candidates for partial adhesive
restorations (less compromised teeth) are
usually limited in the periphery and localized
above the bone. This means that these
­areas can often be transformed into supra-
gingival areas with the removal of periodon-
tal tissue (gingivectomies or osteotomies)
and/or with margin relocation techniques –
a direct restoration previous to the final indi-
rect one – with the goal of creating a new
accessible margin.2,3 If the restorative deci-
sion is to create a full-contour resistive
crown, there is usually significant structure
loss. In this situation, the goal of managing
subgingival margins is usually to achieve a
“ferrule” design. Gingivectomies and oste-
otomies can also be helpful to achieve this
goal, but other techniques can be neces-
sary or preferable, eg, the use of a deep sub-
gingival vertical preparation, assuming the
fracture as the vertical preparation or extru-
sion, as is discussed below ­(Table 1).
Periodontal response to
subgingival restorative materials
Tissue behavior when restorative materials
are placed into the supracrestal tissue at-
tachment (traditionally referred to as “bio-
logic width”) has been a matter of debate for
decades. This band of tissue, the dentogingi-
val unit, is composed of supracrestal con-
nective tissue attachment, collagen fibers
connected to the cementum forming a seal,
and, more coronally, the junctional epithe-
lium and then the sulcus. The junctional epi-
thelium is attached to the tooth surface;
where it is the first line of defense where
bacterial toxins and inflammatory processes
take place. Margin placement should ideally
 Cardoso et al

REMOVE CARIOUS AND UNSUPPORTED TISSUE …

1ST – DECISION ON CUSP COVERAGE

CENTRAL CAVITY DEPTH CENTRAL CAVITY DEPTH

≤ 4 mm (VITAL TEETH) > 4 mm (ETT)

All remaining walls ≥ 1 mm
(≥ 2 mm for high functional risk)
NO cracks
Some remaining walls < 1 mm Some remaining walls ≤ 3 mm
All remaining walls
(< 2 mm for high functional risk) OR high funcional risk
> 3 mm
OR cracks OR cracks

REDUCE THIN WALLS VERTICALLY UNTIL 1-MM THICKNESS IS REACHED …

2ND – DECISION ON AXIAL EXTENSION OF THE CUSP COVERAGE

MILD MODERATE SEVERE

TISSUE LOSS TISSUE LOSS TISSUE LOSS

Wall height > 3 mm Wall height > 3 mm Wall height > 3 mm

in more than 2/3 between 1/3 – 2/3 in less than 1/3
of the periphery of the periphery of the periphery

ADHESION ADHESION RESISTANCE

OVERLAY W/ AXIAL PREPARATION

“TABLE TOP” OVERLAY CROWN
ADHESIVE CROWN OR ENDOCROWN

3RD – MANAGING SUBGINGIVAL AREAS FOR ADAPTATION AND “FERRULE”

GINGIVECTOMY GINGIVECTOMY

DEEP SUBGINGIVAL
OSSEOUS

MARGIN ELEVATION
SUPRA-­

VERTICAL PREPARATION

OSTEOTOMY MARGIN ELEVATION OSTEOTOMY

EXTRUSION
EXTRUSION ASSUME FRACTURE AS
OSSEOUS
INFRA-­

VERTICAL PREPARATION
OSTEOTOMY
OSTEOTOMY

CONSIDER EXTRACTION IF “FERRULE” IS NOT POSSIBLE

Fig 1 Decision chart for posterior teeth for cusp coverage, axial extension, and subgingival management.

The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024 | 17

Clinical Research

Table 1 Management options for supraosseous or infraosseous subgingival margins

Supraosseous Infra­osseous

Subgingival margin management options and main indications in posterior teeth

Gingi­ ■ Selective soft tissue removal can provide space for retraction and
 vectomy isolation instruments for appropriate marginal access
■ Bone removal to allow accessible margin after healing presents po-
tential problems:
 Osteotomy
– papilla loss in interproximal area causing food impaction
– loss of bone for future implant placement in extreme cases
Margin ■ Indicated if overall structural analysis suggests a partial adhesive res­
 elevation toration although could also be used in crowns
■ May allow an easier gain in ferrule design with subgingival engage-
Deep ment without excessive tooth preparation
subgingival
 vertical
■ Indicated if overall structural analysis suggests a full-contour resistive
restoration
preparation
■ Evaluate and manage periodontal risk
■ Indicated in subgingival margins created by oblique fractures that do
Assume not compromise tooth viability or a “ferrule” design, without carious
fracture
  vertical
tissue, and where a new dentogingival complex can reestablish;
then, proceed to the final restoration – often a resistive vertical prep-
margin
aration crown is indicated
■ Surgical or orthodontic extrusion is indicated whenever more addi-
  Extrusion tional “ferrule” design is needed, while allowing remaining root struc-
ture for tooth viability

be supragingival, especially if no esthetic re-
quirements are present. However, patients
who perform good oral hygiene can have
intrasulcular margins without any detrimen-
tal effects.4 Human studies show that mar-
gins placed deeper than the sulcus, into the
supracrestal tissue attachment, can either
cause a) tissue recession to reestablish a lon-
ger bone-to-margin distance, or b) chronic
inflammation.5 Anticipating these distinct
consequences is not predictable.6 Although
it seems clear that the impingement of the
deeper connective tissue will trigger inflam-
mation and/or bone and soft tissue loss,
there is no consensus to date as to whether
placing the margin in the junctional epithe-
lium will also have the same detrimental ef-
fect.4 It has been suggested that periodontal
biotype (soft and hard tissue thickness and
architecture),7 type of material, restorative
margin design, and fitting accuracy also play
a role in the type of soft tissue response.5
Gingivectomies and cervical
margin relocation in adhesive
restorations
In cases of supraosseous and shallow sub-
gingival defects, a simple gingivectomy can
be sufficient to allow proper access. The pa-
pilla and soft issue in the interproximal area
are often an impediment for the proper pos-

18 | The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024

 Cardoso et al

Subgingival and supraosseous margin management with gingivectomy and cervical margin relocation/elevation

a b c

d e f

Fig 2a to f Gingivectomy helps for margin relocation or elevation in subgingival but supraosseous margins.

itioning of the clamp, matrices, wedges, and
rubber dam. When an adequate soft tissue
volume is removed in those areas, for exam-
ple with the use of laser or electrocautery,
the build-up adhesive procedure, impres-
sions, and final restoration can be per-
formed with rubber dam isolation in optimal
conditions. Soft tissue healing is dependent
on the amount of tissue removal and bone
exposure. In extreme cases, if bone is ex-
posed, soft tissue rebound can take 4 to 5
weeks, and the alveolar crest loss can be up
to 1 mm.8 A minimum of 2 mm of attached
gingiva should be retained,4 and margin
placement should respect periodontal
health, as discussed above. In deeper (but
still supraosseous) subgingival areas, the ad-
ditional elevation of the margin is required.
This way, a new margin can remain perma-
nently above the gingiva even after the soft
tissue reestablishes itself coronally in the fol-
lowing weeks. Cervical margin relocation is
a procedure where subgingival areas are
preliminarily restored in order to create a
supragingival margin with a direct material
(usually composite resin). The technique
was introduced by Dietschi and Spreafico,3
and was later called “deep margin eleva-
tion.”2 The goal of the procedure is to make
impressions and cementation easier with a
supragingival margin that facilitates a) mar-
gin identification at the impression, and b)
easier and more stable use of rubber dam
for luting the indirect restoration (Figs 2
and 3). The main concern with the tech-
nique is the stability of the interface of the
preliminary restoration with dentin and ce-
mentum. Adhesion to these deep areas
presents challenges in terms of adaptation,
leakage, and questionable inherent bonding
quality and deterioration.9 Nevertheless, in
vitro studies show improved biomechanical
properties when margin relocation is per-
formed.10,11 Additionally, the interface of

The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024 | 19

Clinical Research

a b

c d

e f

Fig 3a to h Initial situation: tooth 36 with existing endodontic

treatment and extensive amalgam restoration with clinical signs of
secondary caries and overhanging margins (a). Isolation and removal
of existing restoration showing clinical signs of secondary caries and
enamel cracks (b). After caries removal and the reduction of the thin
walls, about 40% to 50% remained of the periphery with walls above
the equator (above a height of 3 mm). An adhesive restoration with
axial chamfer as an additional resistive design was planned. Since
the subgingival margins were supraosseous and an adequate
isolation could be achieved, a margin elevation procedure was
g performed (c to f). Final result (g).

20 | The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024


INDIRECT
RESTORATION
MARGIN
ELEVATION
margin elevation seems to remain stable in
the long term in clinical studies.12,13
This preliminary direct restoration should
have an emergence profile that is divergent
until it is clearly above the gingiva (about 1
to 2 mm), but it should not continue to par-
ticipate in the contact point. The indirect
material should be maximized relative to the
preliminary direct restoration, since the for-
mer allows for better anatomy and physical
properties. Gingivectomies are helpful to
expose the supraosseous remaining struc-
ture and allow rubber dam or clamp place-
ment, as previously mentioned. Teflon tape
to displace the soft tissue, specifically
curved matrices and wedges, has been sug-
gested by some authors as an essential tool
for this procedure.
A common doubt relates to how deep
the margin can be in order to be able to ap-
ply the technique. It is important to realize
that it is not possible to elevate a margin
that is below bone level, for the simple rea-
son that it is physically impossible to stabil-
ize a matrix in this situation. Therefore, since
an infraosseous margin cannot be isolated,
Cardoso et al
Fig 3a to h (cont)
Initial and final
radiographs showing
areas of the direct
restoration for margin
elevation and the
indirect ceramic
restoration (h).
margin relocation procedures are limited to
subgingival but supraosseous defects. Some
human clinical studies that specifically ad-
dress this technique when supracrestal tis-
sue attachment is not invaded show no in-
creased negative periodontal parameters,14
while others show more bleeding on prob-
ing at these sites but without significant
bone loss at 12 months.12,15 There is still a
lack of reliable data regarding periodontal
responses when this technique is used in
deeper lesions, closer to the bone crest. It is
reasonable to assume that similar reactions
to those in animal histologic studies will oc-
cur – when a restoration infringes on the
junctional epithelium or connective tissue,
there is an apical reorganization of tissue,
sometimes accompanied by a soft tissue in-
flammation response that can be transitory
and without clinically significant negative
effects. The reaction is also dependent on
the material (more favorable in composite
and resin-modified glass ionomer) and on
the gingival biotype.5 However, when faced
with other options such as osseous crown
lengthening, the evidence to date seems to
The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024 | 21
Clinical Research
clearly support this minimally invasive tech-
nique, providing proper patient oral hygiene
is maintained and controlled.16
Osteotomy for crown lengthening
In infraosseous margins, more effective pro-
cedures to expose the remaining structure
may be considered such as osseous reduc-
tion. Typical cases include tissue destruc-
tion due to caries or fractures below the
bone level. However, it poses some specific
concerns:
■ Interproximal bone reduction will reduce
the papilla volume, causing food impac-
tion (from the lingual or buccal direc-
tions) in the interproximal space, even
with well-restored contact points.
■ Root furcation poses a limit to bone re-
duction.
■ Osseous reductions of 2 to 3 mm in pos-
terior teeth may compromise or compli-
cate the future possibility of a dental im-
plant, causing insufficient remaining
vertical bone due to anatomical limita-
tions such as the maxillary sinus or the
mandibular alveolar nerve.
Given these implications, the present au-
thors believe that minor osseous reductions
can be helpful, but significant osteotomies
of more than 2 to 3 mm in posterior teeth
should be avoided. A recent systematic re-
view concluded that margin relocation pro-
vides better clinical outcomes compared
with crown lengthening.16
Remaining tooth structure, “ferrule”
design, and subgingival placement
As explained in Part I of this article series,
the present authors rely on the relative
amount of wall thickness above the equator
in the tooth’s periphery as the basis of a
thought process to decide the type of res­
toration – adhesive, resistive or a combina-
22 | The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024
tion of both. Whenever the remaining walls
above the equator (where enamel is thicker
than 1 mm)17 are present in less than one
third of the complete periphery of the tooth,
it is considered that a retentive crown might
be indicated, even though the minimal
amount of enamel needed for an adhesive
restoration to be clinically successful in the
medium to long term is not known (Fig 1).
The “ferrule” effect has been considered the
most important factor for survival of the res­
toration and root, being more important
than, for example, the presence or type of
posts.18-21 The “ferrule” seems effective when
the encircled residual tooth structure has a)
2 mm of height, b) 1 mm of thickness, c) ta-
per less than 10 degrees, and d) tissue pre-
sent buccally and lingually (the crown can
seat onto the buildup/margin relocation
mesially and distally).18
When the “ferrule” effect is somehow
compromised due to scarcity in height and
thickness of the residual tooth structure, it is
important to consider restorative strategies
that may reestablish or complement this
limitation. Some suggested strategies in-
clude the use of posts, crown lengthening,
orthodontic extrusion, surgical extrusion,
and even splinting to adjacent teeth ­(Table 1).
If none of these strategies can guarantee
the “ferrule” effect while maintaining tooth
periodontal tissue support and health, then
tooth extraction needs to be considered,
and alternatives for tooth replacement
should be discussed with the patient to
avoid unrealistic expectations.
Posts and reinforced materials for the
core or buildup
No-post approaches have been suggested,
based on some in vitro studies, where maxi­
mizing adhesion would better transfer stress
within the tooth structure.22-24 However, a
systematic review and meta-analysis of in
vitro studies showed increased fracture re-

sistance when posts were used in pre-
molars, for example.25 Some clinical studies
show long-term benefits of posts in endo­
dontically treated premolars restored with
direct adhesive restorations26 and cemented
crowns27 regarding the survival of both the
restoration and the tooth.
The fact that the “ferrule” design seems
to play a more important role than the use
of posts18 has led to what seems a partially
incorrect belief that the main reason to use
a post is uniquely to retain the core to sus-
tain a restoration. Perhaps a more compre-
hensive approach lies in the explanation
that posts can play a role in core retention,
but their utility is mainly to complement the
effect of the “ferrule” by “preventing the
tooth/core/post complex, on which a fer-
rule is cemented, from separating from the
abutment root at a fracture plane that is lo-
cated approximately and theoretically at the
level of the crown or ferrule margin,” using
adhesive approaches as much as possible.28
In the same line of thought, it has been sug-
gested to use fiber-reinforced direct com-
posite as an alternative to posts, and even to
reduce the need for cusp coverage.29,30
Some studies suggest that these materials
reinforce the load-bearing capacity of root
canal-treated teeth.31,32 Other studies
demonstrate that these fiber-reinforced dir-
ect composites cannot reduce the need for
posts33 and may not provide more benefits
than conventional composites.34,35
Fiber posts seem to have a better long-
term prognosis than metal posts, according
to some studies.36,37 The failure mode of
fiber posts has been related to retention loss
and less catastrophic root fractures com-
pared with metal posts.37 However, this dis-
tinct failure pattern has not been confirmed
in other reviews.36,38,39 Probably due to the
more horizontal occlusal load (tensional
stresses), incisors, canines, and premolars
seem to benefit from posts more than m ­ olar
teeth do.18,40
Cardoso et al
Despite some basic ideas, no fundamen-
talist doctrines for or against the use of
posts (or their relative advantages) have
been clearly supported by scientific evi-
dence. What seems clear is that efforts
should be made to preserve tooth structure
and maximize the possibilities for the “fer-
rule” effect design with healthy tooth struc-
ture. Furthermore, if a post is used, it should
not be at the cost of additional canal prep-
aration that can contribute to further struc-
tural fragility; instead, a post should be used
that can adapt to the original canal width.24
Additional retention in deep
subgingival vertical preparations
Where there is a lack of sufficient residual
tooth structure to provide an effective “fer-
rule” effect, alternative strategies must be
considered (Figs 4 and 5). An often-forgotten
strategy is the use of the subgingival tooth
structure onto which the restoration can en-
gage in order to create a valid “ferrule” effect,
as explained in Part II of this article series. The
obvious issue with this approach is the pos-
sible violation of the supracrestal tissue at-
tachment (“biologic width”). In most situ­
ations of healthy periodontium, below the
gingival margins there is an additional 1 to
3 mm of tooth tissue in the sulcus, easily de-
tected by probing, which can be used to cre-
ate further “ferrule” height. In case deeper
margins for adequate “ferrule” are needed, it
is not clear whether placing the margin into
the junctional epithelium may eventually be
tolerated, as explained above;4 therefore, go-
ing no deeper than the sulcus is the safest
option. If deeper engagement is needed for
the “ferrule,” remaining within the junctional
epithelium, 1 mm away from the bone and
avoiding the supracrestal connective tissue
attachment, is the absolute limit, after which
bone loss and/or inflammation will certainly
occur.6 If this latter approach is decided upon,
it is important to consider a few factors:
The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024 | 23
Clinical Research

Subgingival and supraosseous margin management with deep subgingival vertical preparations

a b c

d e f

Fig 4a to f Initial situation with nonexistent “ferrule” (a). For previous build-up gingivectomies where Teflon tape will allow proper isolation
(b and c). Preparation disrupting the supracrestal connective tissue (d). Additional gingivectomy to open the space for a same-day impression
to capture deep areas before tissue rebound (e). Margin placement not closer than 1 mm from the bone in order to avoid connective tissue
impingement (f).

■ An “edgeless” vertical preparation, specif-
ically for compromised teeth, will allow a
deeper margin (see Part II of this article
series).
■ The chances of periodontal inflamma-
tion should be weighed against the
tooth-saving benefits, and clear patient
communication should be provided re-
garding the risks.
■ The patient’s motivation to maintain op-
timal oral hygiene should be established
and the periodontal risk assessed.
■ Gingivectomies to allow proper rubber
dam isolation for previous buildups may
facilitate this procedure.
■ To achieve access to more apical areas,
electrocautery can be used parallel to
the tooth axis to create a temporary
deeper sulcus without removing tissue
vertically. This will ensure blood clot sta-
bilization and protect any exposed bone,
to avoid patient discomfort.
■ Aluminum chloride paste can be helpful
for hemostasis control.
■ Performing a same-day impression will
allow the capture of deeper areas before
soft tissue rebound takes place during
the healing process.
■ It is critical to evaluate the depth of the
impression or scan and instruct the den-
tal laboratory technician not to go closer
than 1 mm from the bone level.
■ The goal is to try to achieve 2 mm of ver-
tical tooth structure to which the crown
can engage (“ferrule”), while placing the
margin no closer than 1 mm from the
bone level.

24 | The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024

 Cardoso et al

a b

c d

Fig 5a to d Mandibular left second premolar with a history of dislodgement of several previously made crowns. Minimal or borderline
“ferrule” above the gingival level at the existing margin would explain the ongoing lack of success. It was decided to gain subgingival “ferrule”
to try to save the tooth, while placing the margin into the junctional epithelium, assuming some periodontal risks (a). Post, buildup, gingivec-
tomy, and a deep vertical edgeless preparation were performed to maximize the “ferrule” design using subgingival tooth structure (b).
Situation 3 years postoperatively showing the new crown without any episode of dislodgement or symptoms. Periodontal response with no
signs of inflammation (c). Situation preoperatively and 3 years postoperatively showing a deep margin placement and no significant signs of
bone resorption. Although it may seem from the radiographs that the margin is excessively close to the bone, in fact it was controlled
through proper laboratory communication to maintain a 1-mm distance from the bone (d).

In any type of zirconia restoration, the subgin- Management of subgingival

gival areas should be monolithic and polished,
but nonglazed, in order to optimize biocom-
patibility and tissue tolerance (Fig 5).41 Also,
the marginal thickness should not be more
than 0.2 mm in order to minimize the chance
of eliciting a periodontal reaction (Fig 5).5,42 In-
dependently of how deep clinicians are will-
ing to go into the periodontal tissue, vertical
preparations seem to be the most rational
option in these cases, since shoulders or
chamfers would unnecessarily remove more
tooth structure and compromise the horizon-
tal thickness of the “ferrule” wall.
fractures
Cases involving fractures should be con-
sidered differently to those involving caries
(Figs 6 and 7). Oblique fractures have been
traditionally treated with difficult tissue re-
traction and rubber dam isolation tech-
niques or bone reduction, with the disad-
vantages that are explained above. However,
the present authors propose a less invasive
approach where fractures can be regarded
as accidental “vertical preparations” or “root
concavities.” As explained in Part II of this ar-

The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024 | 25

Clinical Research

Fig 6a to d In cases
of subgingival and Management of subgingival infraosseous fractures by assuming a new margin
infraosseous oblique after soft tissue healing
fractures with a
remaining “ferrule”
design that are
indicated for a
full-contour resistive
crown, allowing the
tissue to heal and
remodeling the area
can be an option.
After periodontal a b
remodeling, the
affected area is itself
considered to be a
vertical preparation,
and a full-contour
resistive crown can
be performed with
no further prepar-
ation required in the c d
fracture area.

ticle series, a subgingival feather-edge prep- or orthodontically, achieving a minimum of

aration will result in a new supracrestal at-
tachment established in the prepared root
surface43 and will potentially increase the
tissue thickness and stability.44 Therefore, a
legitimate option for fractures might be to
let the tissue heal and increase its thickness
around the affected area, and then to have
the remaining supragingival structure re-
stored. However, this can only be con-
sidered in localized fractures that do not risk
the biomechanical stability of the tooth, as-
suring the necessary wall dimensions for a
“ferrule” design.
Orthodontic and surgical
extrusion for additional retention
or “ferrule”
At least from a conceptual point of view, ex-
trusion is a very appealing strategy. The goal
would be to get the root out of the bone
socket, which can be performed surgically
4 mm of tissue above the alveolar bone so
that a 2-mm “ferrule” can be attained with-
out the risk of supracrestal tissue impinge-
ment (Figs 8 and 9).4 A crown-to-root ratio
of around 1:1 has been advocated, but it
may not be as important as was previously
thought for long-term tooth maintenance,45
so this should not be an absolute limitation
for these techniques.
The aim of orthodontic extrusion to in-
crease the “ferrule” would be to expose
more tooth area by moving it in the occlusal
direction, without the traction of soft tissue
or bone. This is a distinctly different move-
ment from regular orthodontic movements
that intend to drag bone and soft tissue. The
orthodontic extrusion effect, also known as
“forced eruption” or “rapid extrusion,” can
be achieved with heavy (above 50 g), con-
tinuous forces, and anchorage can be used
on adjacent teeth or implants (Fig 8).46
Supra­ crestal fiberotomy and root planing

26 | The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024

 Cardoso et al

a b c d

e f g h

i j k

Fig 7a to k Subgingival fracture at the bone level in the mesiopalatal area (a). No procedure was performed, and the soft tissue was left to
heal for 6 weeks. Removal of the existing restoration and evaluation of the remaining structure. More than two thirds of the periphery was
deprived of enamel; therefore, a resistive restoration (crown) was indicated. Isolation for a core buildup without any attempt to rebuild the
subgingival area of the fracture that extended until the bone – that area is considered to have been “prepared vertically” by the fracture itself.
Posts were used in a minimally invasive approach without any further canal preparation (b to d). Tissue retraction previous to the impression.
The fractured area developed a healed sulcus, which was managed similarly to other nonfractured areas (e to g). Occlusal view 5 years after
delivery (h). Palatal view 5 years after delivery. The initial bone-level fracture zone, located in the mesiolingual area, shows no clinical signs of
periodontal problems (i). Initial radiograph (j). 5-year postdelivery radiograph showing apparently stable interproximal bone levels (k).

The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024 | 27

Clinical Research

a b

c d

e g h

i j k l

Fig 8a to l Initial situation with severely compromised height and thickness of tooth (a). Isolation for endodontic treatment and core buildup
with posts (b). Rigid wire bonded to adjacent teeth for anchorage (c). Rigid metal wire bonded to the core and activated for extrusion using
an elastic power chain (d). Vertical preparation with a reverse shoulder (see Part II of this article series) and increased “ferrule” (e and f).
Monolithic zirconia crown (g and h). Initial radiograph (i). 2-week postoperative radiograph (j). 4-week postoperative radiograph (k). Final
restoration radiograph (l).

28 | The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024


during the procedure may help to prevent
soft tissue dragging or reattachment and to
minimize relapse.46 A time period of 1 to 3
weeks may be needed for each millimeter
of extrusion depending on the bone density
and root surface area.47
Surgical extrusion is a one-step proced-
ure in which the tooth is partially removed
from the socket, with minimal trauma, caus-
ing more tooth structure to be exposed and
available for restorative purposes (Fig 9).47
The periodontal ligament is left to heal with
a splinting stabilization period of no longer
than 3 weeks in order to minimize the risk of
ankylosis.47 The necessary endodontic treat-
ment can be performed as soon as tooth
mobility is reduced, at around 4 weeks, if it
was not structurally possible to do so before
the extrusion. Restorative procedures can
start at 6 to 8 weeks, when bone apposition
in the alveolar socket is evident.47
There are no available data regarding
serious complications of orthodontic extru-
sion but it seems reasonable to consider
them to be fewer than for surgical extru-
sion. However, surgical extrusion can be
achieved at a much faster pace, with lower
costs for the patient. Complications that
can lead to tooth loss with surgical extru-
sion seem to be less than 10% in the long
term,48,49 which makes it a very reasonable
technique when extraction is considered,
compared with the biologic risks and finan-
cial costs of dental implants, as long as
proper patient information is assured.50
Splinting to adjacent teeth
Even though the present authors are not
aware of any suggestion in the literature for
splinting adjacent teeth for additional reten-
tion, with a compromised “ferrule” design it
can be an option in selected situations.
When faced with two or more adjacent
teeth that need to be restored with full-con-
tour retentive crowns, and when one of
Cardoso et al
them has insufficient “ferrule,” providing a
fixed bridge may reduce failures. The disad-
vantage would be that interproximal oral hy-
giene would be more difficult to perform;
however, the option can still be very suc-
cessful in highly compliant patients.51
Conclusions for subgingival
management, “ferrule” design, and
management of severely
compromised teeth within the
CARES concept
In order to correctly manage subgingival
­areas, it is important to follow a structured
thought process for diagnosis (Fig 1). For ad-
hesive restorations where a limited area is
located subgingivally, the recommended
approaches would be to perform periodon-
tal soft or hard tissue removal and/or mar-
gin elevation in the affected zones. In case
of full-contour resistive crowns, the man-
agement of subgingival areas usually aims at
creating a “ferrule” design. Depending on
the depth of the subgingival defect (supra-
or infraosseous), possible approaches in-
clude periodontal soft or hard tissue re-
moval as well as using deep subgingival
vertical preparations or, in case of fracture,
assuming it as the vertical margin after heal-
ing if “ferrule” is still possible.
Subgingival but supraosseous margins:
■ In shallow margins, these situations can
be solved with gingivectomies and/or ef-
ficient soft tissue retraction with Teflon
tape and rubber dam with a clamp for
proper access.
■ In the case of adhesive restorations, mar-
gin relocation will allow the creation of a
new accessible margin for impressions
and bonding procedures.
■ Deep subgingival vertical preparations
can be used to gain “ferrule” if the
planned restoration is a resistive crown.
This technique needs to carefully man-
age periodontal risks.
The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024 | 29
Clinical Research

c b

d e f

Fig 9a to m Buccal and occlusal views of the initial situation of the maxillary right second premolar with adequate “ferrule” for restorability
(a and b). Surgical extrusion where the tooth was luxated and moved out of the socket to create adequate “ferrule” and was splinted to the
adjacent teeth (c). Initial radiograph (d). Radiograph of endodontic retreatment procedure (e). 8-week radiograph after extrusion showing
evident bone formation in the apical region (f).

30 | The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024

 Cardoso et al

g h i

Fig 9a to m (cont) Tooth buildup 8 weeks after surgical extrusion (g). Digital impression for
a new crown over the existing implant on the maxillary right second molar (after soft tissue
augmentation) and a crown over the extruded tooth (h). Monolithic stained zirconia crowns
with polished subgingival areas (i). Buccal view of the final result 3 years postoperatively (j).
Occlusal view of final result 3 years postoperatively (k). Initial radiograph (l). 3-year postopera-
m
tive radiograph (m).

The International Journal of Esthetic Dentistry | Volume 19 | Number 1 | Spring 2024 | 31

Clinical Research

Subgingival and infraosseous margins:
■ Osteotomies can be performed, but cer-
tain disadvantages make this procedure
limited in posterior teeth.
■ Assuming the fracture as a vertical mar-
gin after healing is an option if the re-
maining “ferrule” makes the tooth restor-
able.
■ Extrusion procedures are viable options
that can consistently promote “ferrule” de-
signs. Orthodontic and surgical extrusion
both have relative advantages and risks.

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| 33
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