Deep margin elevation

Antoine Ghorayeb MREA 1

Introduction

1) a technical- operative
parameter (possibility
of correct isolation
through the dental
New classification dam)
based on two clinical
parameters
2) a biological
parameter (depending
on the biologic width)
Introduction

Coronal relocation of the

margin

3 clinical situations and 3

Surgical exposure of the
therapeutic approaches
margin
are identified

Associated with 3 further

operative sequences:
Clinical crown
immediate, early, or
lengthening
delayed impression
taking
Introduction

Problems are linked to polymerization

contraction and dentinal adhesion
Objectives
Restore correct biologic width in relation to the positioning
of the restoration, conservation, or prosthetic margins

Re-establish correct occlusal function

Restore the morphological and, if possible, esthetic integrity

of the tooth

Guarantee excellent coronal marginal sealing

 Polymerization

To counter-act polymerization
The effects of polymerization

Glass or ceramic
In relation to the cavity, with bases

contraction
possible distortions or micro-
fractures of the walls themselves
stress

At marginal interface adhesive level

Multi-layered
(with consequent micro-infiltration),
or internal (with consequent
techniques
compression hypersensitivity
Thin layer of resin
used for cementing
Adhesion

While adhesion to mordant-treated enamel is predictable and

safe, adhesion to dentin and cementum is dependent on
numerous and complex phenomena.
Preserve as much residual healthy tissue as possible and
obtain a thin smooth layer of adhesive cement by means of a
buildup in order to control contraction stress during
cementing.
Coronal margin relocation

In cases with slightly subgingival margins, it is possible to relocate the cervical preparation to
above gingival levels by applying an appropriate increment of composite resin over the pre-
existing margin.

Rigorous isolation of the field with a dental dam, positioning of a matrix to guarantee a cervical
seal, thorough cleansing of the cavity finishing with a bicarbonate spray, adhesive phase with a
three-step etch-and-rinse method, and raising of the cervical step with flowable composite of
maximum 1 mm thickness.

Use of flowable composite → higher volumetric contraction but lower stress contraction
Use of flowable composite at the cervical level in the absence of
enamel can be supported according to the following rationale:

Interposition of an “elastic layer”

of controlled thickness (0.5 to 1
mm) between the dental
Straightening of the cervical
substratum and restoration Fluid adaptation to the cavity floor
margin
material → This allows contraction
stress to be absorbed and the
adhesive interface to be preserved

Composite-composite adhesion is
Immediate dentin sealing Protection of the adhesive film
possible and efficient
The classification is based on two decision-
making parameters in clinical order:

1) technical-operating parameter: possibility of a correct

isolation of the field with rubber dental dam.

2) biological parameter: measuring the distance between

the cleansed cervical margin and periodontal attachment, or
the bone crest, with a periodontal probe and radiography.
Three different clinical situations are identified and
defined according to their importance in three grades:

Grade 1: the rubber dam, correctly sheathed in the sulcus, is sufficient

to show cervical margin with an adequately prepared cavity.

Grade 2: the rubber dam does not allow a correct isolation of the
field, but the biologic width is respected.

Grade 3: the cavity cervical margin (following carious lesions or

coronal fracture) is subgingival with violation of the biologic width.
Differentiated therapeutic approach

Grade 1: coronal relocation of the margin using flowable composite with a maximum
thickness of 1 to 1.5 mm, followed by buildup, preparation, and impression. Adhesive
cementing of the Onlay after 7 days.

Grade 2: surgical exposition of the margin using flowable composite of 0.5 mm thickness
at the cervical margin level followed by buildup, preparation, and immediate impression.
Adhesive cementing of Onlay 7 days after removal of the sutures.

Grade 3: surgical lengthening of the clinical crown using three different operative
sequences depending on different clinical situations: a)immediate impression, b)early
impression, and c)delayed impression.
Differentiated therapeutic approach

3a) surgical crown lengthening, positioning of the rubber dam, flowable composite at cervical
level of 0.5mm controlled thickness followed by buildup, preparation, and immediate post-
surgical impression. Single vital teeth or those already treated endodontically.

3b) surgical crown lengthening and pre-endodontic reconstruction in first appointment, canal
therapy in a second appointment, and then early impression taking at 3 weeks and endodontic
treatment has not yet been carried out.

3c) surgical crown lengthening, temporary reconstructions (pre-endondontic) in glass ionomer

cement with impression delayed for 8 to 12 weeks. For multiple restorations, quadrant
rehabilitations, or complex cases with possible prosthetic treatment of several elements.
The DME technique

• Placement of a modified Tofflemire matrix followed by immediate dentin

sealing and coronal elevation of the deep margin to a supra-gingival position
using a direct bonded composite resin base.
The DME
technique
The DME technique
 • 1. A curved matrix (Greater Curve or similar “banana matrix”) should be favored → gingival emergence profile
and contour.
• 2. Sufficient buccal and lingual walls of the residual tooth structure must be present to support the matrix.
• 3. The matrix height should be reduced to 2 to 3 mm (slightly higher than the desired elevation).
• 4. For endodontically treated teeth, the clinician must ensure that successful root canal therapy has been
achieved. Further, a glass-ionomer barrier should be placed to cover the access to the canals. DME can also be

Fundamental
used to establish proper isolation prior to root canal therapy.
• 5. After placing the matrix, the gingival margin must be sealed by the matrix, and no gingival tissue or rubber dam
should remain between the margin and matrix.

elements for • 6. Prior to bonding, the margin should be gently re-prepared using a fine diamond bur with abundant water spray.
This will ensure the elimination of debris and other contamination of the dentin that may have occurred during
matrix placement.

successful • 7. Immediate Dentin Sealing should be applied using a three-step, etch-and-rinse dentin adhesive (eg, Optibond
FL, Kerr) to the preparation in the presence of the matrix, followed by placement of a composite resin base that
will relocate the margin by approximately 2 mm (one to two increments). This part of the procedure is like direct

DME:
composite resin restoration.
• 8. Various types of composite resin can be used for elevation (traditional restorative or flowable).
• 9. Once the margin is elevated, the preparation can be completed by careful elimination of excess and composite
resin flash around the tooth using a no. 12 blade or a sickle scaler. Interdental flossing is used to check for the
absence of overhangs and flash.
• 10. Finally, a bitewing radiograph should be taken to ensure that no excesses or gaps are present before
proceeding to final preparation and impressions.
• 11. The matrix-in-a-matrix technique represents the final option in case of an extremely deep and localized lesion .
This technique consists of sliding a sectioned fragment of metal matrix between the margin and existing matrix.
The DME
technique
• Currently there is no strong scientific
evidence that could either support or
discourage the use of Cervical Margin
Relocation (CMR) technique prior to
restoration of deep subgingival defects
with indirect adhesive restorations.
Randomized controlled clinical trials are
necessary to provide the reliable evidence
on the influence of CMR technique on the
clinical performance, especially on the
longevity of the restorations and the
periodontal health.