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Clinical Relevance
Advancements in material technology and clinical techniques led to increasing indications
for minimally invasive treatment approaches with direct resin composite restorations.
Proximal box elevation, an example of an elaborate clinical technique, provides a two-step
procedure for the restoration of deep and undermining defects in the proximal area.
of the restoration should be placed within an intact deep occluso-proximal resin composite restorations
enamel layer. However, provided that moisture invading biological width are free of gingival and
control is possible, composite resin restorations can periodontal inflammation, provided that there is
be applied successfully in deeper cavities, even when distinct oral hygiene training and use of accurately
restorative margins are located below the cemento- fitting interdental brushes. This fact leads to the
enamel junction (CEJ).2 A new operational range is hypothesis that subgingival composite resin restora-
thus opened up as the composite resin is located tions fabricated using a two-step R2-technique may
subgingivally adjacent to the junctional epithelium violate the area of biological width without inducing
and alveolar bone crest. Modern application tech- chronic inflammation.
niques allow for the creation of planned and Together with the clinical procedure presented
nonirritating composite resin margins in this area.3,4 here, a stepwise introduction is given to the
A recently described technique, proximal box eleva- restoration of extensively damaged teeth by applying
tion (PBE), offers the possibility of a stepwise a direct composite resin restoration, using the two-
relocation of deep proximal margins to uplift cavity step R2-technique (step one: PBE; step two: direct
outlines for direct or indirect restorations.5,6 Step composite resin restoration). Furthermore, a critical
one (PBE) involves a meticulous layering technique review is given on the consistency of the dogma of
for margin relocation above the CEJ. Step two allows biological width.
the practitioner to decide on whether to place a
direct or indirect restoration under improved clinical CLINICAL TECHNIQUE
conditions.
Patient Presentation
Before restoring extensively decayed teeth, the
distance between the future restorative margin and A 75-year-old female psychologist visited the De-
the alveolar crest should be evaluated carefully, for partment of Conservative Dentistry, Clinic for Oral,
example, by bone sounding. An adequate space for Dental and Maxillofacial Diseases, University Hos-
restorative margin placement can be achieved by pital Heidelberg, with a restoration loss on the
surgical (crown lengthening procedure) or orthodon- mandibular right premolar #45. A review of her
tic treatment (forced eruption).7 medical history revealed no medical disease. She was
a nonsmoker and took no medications. She stated
The physiological dimensions of the dentogingival that she felt no pain on tooth #45. Clinical examina-
junction, with its inherent parts of epithelial attach- tion revealed positive vitality, no tooth mobility, and
ment, connective tissue attachment, and sulcus probing depths of 2 mm.
depth, were first described by Gargiulo and others
in 19618 and reevaluated by Vacek and others in Intraoral evaluation revealed carious decay on the
1994.9 Gargiulo and others described the ideal cervical margin of the cavity reaching beyond the
dimension of the dentogingival junction to be 2.73 CEJ. The proximal margin was partly covered by
mm and Vacek and others determined it to be 3.25 overgrowing gingival tissue (Figure 1). Radiographic
mm.9 Based on these reports, a distance of 3 mm and examination of tooth #45 revealed that there was no
more is recommended between restorative margins periapical translucency and that the distance be-
and the alveolar crest to avoid detrimental effects on tween the cavity margin and the alveolar bone crest
neighboring soft and hard tissues.10-13 In restorative was between 0.5 mm and 1.0 mm (Figure 2). As the
terminology this distance is generally called biolog- proximal cavity margin was already beyond the CEJ
ical width. invading biological width, it was assumed that after
caries removal it would be located at the level of the
Violations of the biological width resulting from alveolar crest. It was explained to the patient that
intracrevicular placement of restorative margins can the gold-standard treatment would be placement of
result in severe gingival inflammation,4 loss of an indirect partial or full crown in combination with
periodontal attachment, and bone resorption.11,15 surgical or orthodontic pretreatment. Alternatively,
Furthermore, marginal overhangs of direct and it was clarified that if the marginal ridge was still
indirect restorations are related closely to elevated intact, a direct restoration with composite resin
plaque accumulation, microbiological diversification, could be an option. However, it was also explained
and increasing chronic inflammation of soft and hard that the outcome of this procedure would be less
tissue.16 predictable than that of an indirect restoration. The
Clinical observations in our department revealed patient favored a restoration with direct composite
that plain, smooth, and nonirritating margins on resin to avoid surgical or orthodontic interventions.
24 Operative Dentistry
Figure 3. R2-technique: Placement of a direct resin composite Figure 5. After etching, priming, and bonding, a layer of flowable
restoration in the two-step technique. Step one (PBE): Clinical composite was placed meticulously on the cavity margin, followed by
situation after gingivectomy (Elektrotom) and caries excavation. The a layer of viscous resin composite (both unpolymerized). After
proximal cavity margin is located below the CEJ next to the alveolar modeling and shaping both materials, the final light polymerization
crest. was carried out (Snowplough technique).
Figure 4. Application of a retraction cord. The cord could not be Figure 6. Schematic drawing of Snowplough technique: Note that in
inserted fully into the sulcus because of the proximity of the alveolar clinical practice there is a narrow and sharp angled junction between
crest. Subsequently, an astringent paste was applied for 2 min. PBE placed in step one and the sectional matrix.
26 Operative Dentistry
DISCUSSION
Successful and long-term composite resin restoration
of cavities reaching below the CEJ is only possible if
adequate moisture management is possible. During
the first step of the presented two-step R2- tech-
nique, the complex problem of moisture management
and restoration accomplishment is reduced to the
circumscribed area of the proximal box. In this
Figure 11. Postoperative view showing the selection of an accurately comparatively small area of the tooth, contamination
fitting interdental brush. is easier to handle and prevent, even if no rubber
28 Operative Dentistry
distortion.7 At the 12-month follow-up, the radio- lamina under the influence of fibrin.24 It is known
graphic examination revealed a distance of 0.51.0 that epithelial attachment is not specific for one
mm between the restorative margin and the alveolar surface structure. It is capable of being formed on
crest with no signs of clinical inflammation. enamel, cementum, afibrillar cementum, and cuti-
cle.24
How Can These Clinical Observations Be
Explained With the Current Literature? Is Reattachment During Wound Healing on a
Restorative margins completely surrounded by Plain Resin Composite Surface Possible?
sound enamel are an ideal situation for structural On the basis of our clinical observations, it is not
conservation of surrounding soft and hard tissues.21 possible to draw any conclusions about epithelial
Extensive and undermining carious lesions or reattachment on a plain resin composite surface.
severe trauma often provide the possibility of However, a noninflammatory rehabilitation of soft
placing restorative margins in sound enamel. and hard tissue next to deep proximal cavities after
Additionally, the degree of difficulty in placing deep PBE can be achieved with the clinical R2-technique
subgingival restorations increases dramatically presented here.
because of inferior insight into and access to the In restorative dentistry, the search for an ideal
cavity, leading to problematic marginal control, material to restore the apical part of deep proximal
management of undermining areas, and moisture cavities is not new. Glass ionomer cements,25,26
control. polyacid-modified resin composite materials1,27 and
In a literature review, Brunsvold and Lane22 could composite resin systems2 are discussed intensely
show that the prevalence of marginal overhangs was regarding their role in long-term durability. Yet with
between 25% and 76% in all restored surfaces. increased degree of difficulty, there are some
Subgingival restorative margins, and especially substantial factors influencing the long-term out-
marginal overhangs, contribute to plaque accumula- come of a restoration substantially below the CEJ.
tion, chronic inflammation, attachment loss, and The individual skills of the operator28 or the degree
bone resorption.20,22 Molars restored with indirect of contamination with blood or saliva29 are prone to
crowns or direct occluso-proximal restorations the development of secondary caries and/or failure of
showed increased involvement of the furcation a restoration.
compared with sound molars. 23 Furthermore, However in recent years, several new techniques,
Flores-de-Jacoby and others16 reported increased for example the PBE,5,6 the elastic cavity wall,3,4 and
amounts of spirochetes, fusiforms, rods, and fila- the Snowplough technique17 (Figure 6) were devel-
mentous bacteria in subgingival plaque. However, no oped to increase clinical sucess in managing difficult
association was found between restorative margins situations. They provide promising approaches to
below the CEJ and the occurrence of secondary manage complex direct resin restorations on severe-
caries.2 ly decayed teeth. Remarkably, these techniques are
A possible explanation for the sound periodontal mainly designated for building up only parts of
and gingival condition in the presented case may teeth, here proximal areas. It is assumed that the
be the polished, planed, and nonirritating subgin- violation of the biological width within a limited
gival margin, which was created during the first extent, under the precondition of superior oral
step (PBE) of the R2-technique. This, in combina- hygiene, can be successful. Further experimental
tion with the distinct oral hygiene protocol, the and clinical research should be encouraged to gain
individually adapted interdental brushes, and further information on relevant questions, such as
their adequate and regular use, may have contrib- the tolerable extent of violation of the biological
uted to the clinical success at the 12-month follow- width, favorable materials in the subgingival area
up. and their long-term bond strength and surface
We assume that during wound healing an characteristics, and the evaluation of patient char-
epithelial reattachment may have taken place on acteristics.
both the cementum and the apical parts of the
composite resin surface. After iatrogenic detach- CONCLUSION
ment resulting from surgical or restorative proce- Advantages
dures, wound healing takes place, involving 1. The two-step R2-technique (step one: PBE; step
hemidesmosomes and the restructuring of the basal two: direct composite resin restoration) provides
30 Operative Dentistry
an additional treatment option for the restoration ceramic inlays in vitro Clinical Oral Investigations 17(1)
of deep and undermining cavities reaching below 177-183.
the CEJ. 6. Roggendorf MJ, Kramer N, Dippold C, Vosen VE,
2. Distinct oral hygiene training (including the use Naumann M, Jablonski-Momeni A, & Frankenberger R
(2012) Effect of proximal box elevation with resin
of accurately fitting interdental brushes) in
composite on marginal quality of resin composite inlays
patients with occluso-proximal restorations in- in vitro Journal of Dentistry 40(12) 1068-1073.
vading the biological width is necessary to achieve
7. Dibart S, Capri D, Kachouh I, Van Dyke T, & Nunn ME
a noninflammatory clinical situation. (2003) Crown lengthening in mandibular molars: A 5-year
3. It is assumed that the extent of biological width retrospective radiographic analysis Journal of Periodon-
violation plays a role in the biological reaction of tology 74(6) 815-821.
soft and hard tissues: limited proximal area 8. Gargiulo A, Wentz FM, & Orban B (1961) Dimensions and
versus complete circumferential margin. relations of the dentogingival junction in humans Journal
of Periodontology 32(3) 261-267.
Disadvantages 9. Vacek JS, Gher ME, Assad DA, Richardson AC, &
1. The type of restoration, materials used, and Giambarresi LI (1994) The dimensions of the human
dentogingival junction International Journal of Periodon-
marginal quality are determining factors in the tics & Restorative Dentistry 14(2) 154-165.
clinical performance of restorations invading the
10. Ingber JS, Rose LF, & Coslet JG (1977) The biologic
biological width (direct versus indirect restora- widthA concept in periodontics and restorative den-
tions). tistry Alpha Omegan 70(3) 62-65.
2. The reasons for individual variations in biological 11. Nevins M, & Skurow HM (1984) The intracrevicular
response to restorations below the CEJ that are restorative margin, the biologic width, and the mainte-
invading biological width are yet unknown. nance of the gingival margin International Journal of
3. There is no evidence in the literature about the Periodontics & Restorative Dentistry 4(3) 30-49.
long-term bond strength and marginal quality of 12. Gunay H, Seeger A, Tschernitschek H, & Geurtsen W
two-step composite resin restorations. (2000) Placement of the preparation line and periodontal
healthA prospective 2-year clinical study International
Journal of Periodontics & Restorative Dentistry 20(2)
Conflict of Interest 171-181.
The authors of this manuscript certify that they have no 13. Lanning SK, Waldrop TC, Gunsolley JC, & Maynard JG
proprietary, financial, or other personal interest of any nature (2003) Surgical crown lengthening: Evaluation of the
or kind in any product, service, and/or company that is biological width Journal of Periodontology 74(4) 468-474.
presented in this article.
14. Newcomb GM (1974) The relationship between the
(Accepted 26 March 2013) location of subgingival crown margins and gingival
inflammation Journal of Periodontology 45(3) 151-154.
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