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Deep Margin Elevation Versus Crown Lengthening: Biologic Width Revisited
Deep Margin Elevation Versus Crown Lengthening: Biologic Width Revisited
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
70-6.&t/6.#&3tAUTUMN 2018
SARFATI/TIRLET
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
70-6.&t/6.#&3tAUTUMN 2018
CLINICAL RESEARCH
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
70-6.&t/6.#&3tAUTUMN 2018
SARFATI/TIRLET
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
70-6.&t/6.#&3tAUTUMN 2018
CLINICAL RESEARCH
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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SARFATI/TIRLET
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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CLINICAL RESEARCH
the junctional epithelium was shorter, UIF DPOUSPM HSPVQ
EFDSFBTFE JO UIF
the connective attachment longer, and composite group, and all showed a ten-
the bone resorption less important, with dency to decrease in the glass ionomer
sometimes a bone formation into the group. The authors thus concluded that
cavity. There were no differences be- these materials, placed subgingivally,
tween the test groups with regard to the seemed to be well tolerated by the gum.
long junctional epithelium on the ma- According to the authors, the reduced
terial, and the small connective attach- GSFRVFODZPG#01JOUIFJSTUVEZ
EFTQJUF
ment on the root that started underneath the presence of visible plaque, might
the apical limit of the material. None of be explained by plaque composition,
them exhibited bone regeneration. Ac- and also by the fact that the evidence
cording to the authors, these materials showed that gingival response to bio-
seem to have been tolerated subgingi- film may vary between individuals, with
vally, given their good adaptation on the neither quantitative nor qualitative differ-
cavity walls (direct vision through raised ences in plaque accumulation.22 Even
flap in this case), the careful finishing though the roughness of the material
and polishing of the restorations prior surface influences plaque accumula-
to flap closure, and the care taken with tion, there was no evidence of biofilm
bacterial plaque control throughout the composition on it. In this study, the de-
experiment. crease in periodontal pathogens from
Information on the gingival reaction to the red and orange complexes was
subgingival composite can be found in more evident in the glass ionomer group
studies on root coverage procedures. In after 6 months than in the composite
fact, in many clinical situations of gingi- group. The initial pellicle biofilm forma-
val recession, the loss of gingival tissue tion on composite resin could influence
exposing the root can also be associated the adhesion mechanisms of some bac-
with the wearing of the cervical portion terial species. Although the microbio-
of the crown. Thus, as the gum cannot logic results with composite were not as
be replaced higher than the cemento- good as those with glass ionomer, the
enamel junction, the loss of enamel must interesting clinical finding is that the de-
be restored prior to the root coverage crease of pathogens may be related to
procedure.21 the surface aspect of the material after
In 2007, Santos et al17 compared finishing and polishing. This capacity to
coronally advanced flaps performed on obtain a very smooth surface could lead
such roots restored with glass ionomer to a lower plaque adherence and soft
or microfilled composite, and on sound tissue inflammation. Regarding bacter-
roots in the control group. At 6 months, ial adherence and dental plaque accu-
there were no differences between the mulation on these materials, Quyrinen et
HSPVQT JO UFSNT PG QMBRVF JOEFY
#01
al23 studied the influence of roughness
and pocket depth. There were also no and surface free energy on these par-
differences in the percentages of root BNFUFST (JWFO BMM LJOET PG TVSGBDFT JO
DPWFSBHF "NPOH UIF QFSJPEPOUBM the healthy mouth, there is a dynamic
pathogens studied, 10 decreased in balance between retention forces and
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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SARFATI/TIRLET
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
70-6.&t/6.#&3tAUTUMN 2018
CLINICAL RESEARCH
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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SARFATI/TIRLET
Fig 2 Crown lengthening surgery showing a deep Fig 3 Sutures after crown lengthening exposing
cavity. the cavity subgingivally.
Deep margin elevation (DEM) the biotype surrounding the tooth before
choosing this procedure. In fact, Stetler
Dietschi and Spreafico36-38 proposed et al showed that among teeth treat-
a new approach for deep cavities. In- ed with subgingival restorations, those
stead of relocating the margin of the presenting < 2 mm of keratinized tissue
periodontium according to the limits of showed a higher gingival index.
the cavity, they relocated the margin of A randomized clinical trial compared
the restoration coronally to adapt it to the clinical results of crown lengthen-
the periodontium and make the restor- ing and DME in posterior teeth. At 180
ation procedure easier. They called this days, clinical attachment loss was obvi-
cervical margin relocation (CMR), later ously higher in the surgery group, but
called deep margin elevation (DEM) by QMBRVF JOEFY
QPDLFU EFQUI
BOE #01
Magne and Spreafico. This procedure were similar in both groups, suggest-
is based on the ability to get a proper ing that DME was well tolerated by the
isolation after carious tissue removal and periodontium.
the bonding of several layers of com-
posite onto the deep margin, creating Case 1
a new, more coronal restoration margin. "ZFBSPMEQBUJFOUMPTUBOPMENFUBMMJD
(JWFO QSFWJPVT EBUB
JU DBO CF TQFDV- inlay on her first maxillary left molar. Clin-
lated that the gum heals along the com- ical examination revealed an important
posite. However, one must also analyze cavity on the distal aspect of the tooth,
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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CLINICAL RESEARCH
Fig 10 Matrix positioning. Fig 11 Ultrasonic tip to finish carious tissue removal.
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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Fig 14 Flowable composite input on palatal as- Fig 15 Flowable composite input on buccal as-
pect of the cavity. pect of the cavity.
Fig 16 Removal of the matrix. Fig 17 Preparation and polishing of the edges of
the cavity.
was so deep that its limits were not vis- and highlight the remaining carious tis-
ible (Fig 8). A Teflon strip was rolled and TVF 'JH
"UUIBUQPJOU
UIFUJTTVFXBT
placed between the cavity wall and the OPUZFUSFNPWFEJUXBTSFUBJOFEUPIFMQ
rubber dam to improve deep isolation the placement of the matrix that slips
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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CLINICAL RESEARCH
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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SARFATI/TIRLET
Fig 25 Rubber dam placement prior to bonding, Fig 26 Collateral teeth protection.
sandblasting, and etching.
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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CLINICAL RESEARCH
Fig 31 Final bonding. Fig 32 Palatal view showing the composite of the
DME and ceramic overlay.
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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Case 2
The same procedure was performed.
At the 1-year control, the healthy gum
against the mesial composite was ob-
TFSWFE
XJUI OP TXFMMJOH PS #01
OP
pocket depth higher than 3 mm, and no
DMJOJDBMBUUBDINFOU 'JHTUP
Fig 33 Radiographic control.
Fig 34 Clinical view of old composites. Fig 35 Radiograph showing cavity under the
composite.
Fig 36 Deep cavities. Fig 37 IDS and DME with filled flowable composite.
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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CLINICAL RESEARCH
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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SARFATI/TIRLET
Fig 44 Cavity under old composite. Fig 45 Radiograph showing distal deep cavity.
Fig 46 Carious tissue removal. Fig 47 IDS and DME with filled flowable composite.
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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CLINICAL RESEARCH
Case 4
The same procedure was performed. In
this case, the decay was very deep, so
that the rubber dam was pierced dur-
ing its removal. Teflon was used not only
to improve the isolation but also to visu-
alize the exact limits of the carious le-
sion. Two-year control showed an ideal
periodontal integration of the restoration
Fig 52 Deep cavities under old restorations. 'JHTUP
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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Fig 53 Radiographic view prior to Fig 54 Carious tissue removal and rubber dam
treatment. piercing.
Fig 55 Isolation improvement with Teflon and Fig 56 IDS and DME with filled flowable compos-
cavity limits visualization. ite.
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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CLINICAL RESEARCH
Conclusion
From a clinical point of view, DME seems
to be well tolerated by the periodontium
when a good bonding with a proper
isolation is performed, leading to very
few or no signs of clinical inflammation.
From a histologic point of view, it is clear
that no connective attachment could be
obtained on the material, and that DME
did not lead to the recreation of a nor-
mal periodontal attachment, but rath-
er to a different biologic width, mainly
Fig 59 Immediate radiographic control.
composed of a long junctional epithe-
lium and a slight connective attachment
on the dentin below the material. Even
though it is far from the ultimate goal of
a regeneration of a normal attachment
apparatus, this situation seems healthy
and well tolerated by the organisms.
Further clinical and histologic studies
are needed to confirm this conclusion.
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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SARFATI/TIRLET
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THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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CLINICAL RESEARCH
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