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Effect of cervical margin relocation technique with composite resin on the

marginal integrity of a ceramic onlay: a case report

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Effect of cervical margin relocation
technique with composite resin on the
marginal integrity of a ceramic onlay:
a case report
Muneera Abdulaziz Alhassan, BDS ¢ Salwa Omar Bajunaid, BDS, MSc, DABP, FACP
Treatment of a large proximal carious lesion that extends
below the cementoenamel junction is challenging. Large
defects usually require replacement with indirect restora-
tions (inlays, onlays, or crowns). However, when the
gingival cavity margins are deep, operative 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 opera-
tive 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.
Received: November 4, 2019
Accepted: December 4, 2019
Key words: cervical margin relocation, deep gingival
margin, deep margin elevation, proximal box elevation,
proximal caries
Published with permission of the Academy of General Dentistry.
© Copyright 2020 by the Academy of General Dentistry.
All rights reserved. For printed and electronic reprints of this article
for distribution, please contact jkaletha@mossbergco.com.
W ith the increasing use of adhesive restorations,
additional clinical challenges are encountered.
One source of difficulty is a proximal carious
lesion that extends below the cementoenamel junction. Because
of their extensive dimensions, such defects usually neces-
sitate replacement with indirect restorations (inlays, onlays, or
crowns). However, operative procedures for teeth with deep
subgingival margins are complicated, as this clinical situation
may hinder isolation of the operative field, proper cavity prepa-
ration, successful impression-making, and adhesive luting.1-3
There are various approaches to managing such clinical situ-
ations, including crown-lengthening surgery and orthodontic
extrusion of the tooth. In 2012, Magne & Spreafico proposed
a technique they called deep margin elevation as a noninvasive
alternative approach.3 The technique was initially presented in
1998 by Dietschi & Spreafico.4 Composite resin was applied to
form a base that displaced the proximal gingival margins of the
cavity coronally, and subsequently an indirect bonded restora-
tion was placed.4
This deep margin elevation approach, also referred to as cervi-
cal margin relocation (CMR) or proximal box elevation, can be
achieved by carefully placing a direct composite resin restora-
tion following placement of a well-adapted and sealed matrix
to protect the gingival tissue. This base restoration elevates the
gingival margin to a level at which it can be sealed with a rubber
dam, is accessible to impression material or a digital intraoral
scanner, and can be isolated during delivery of the final indirect
restoration.
This technique represents a promising 2-step treatment
approach that can be performed to facilitate impression-making
and rubber dam isolation for safe luting of the final restoration.
Moreover, the adhesive composite resin base is used to seal the
dentin, compensate for limited polymerization in deep boxes,
reinforce undermined cusps, eliminate undercuts, and provide
the necessary geometry for the final restoration.1,3,5 Such CMR
techniques can be performed only if specific criteria are met—
that is, if the gingival margins do not violate the connective
tissue attachment and if a matrix band can be placed so that it is
capable of completely isolating the tooth margins to permit the
placement of a composite resin base.2,5
Multiple in vitro studies have evaluated aspects of margin
elevation techniques.6-10 Rodrigues concluded that the stress
distribution of onlays placed on teeth using a CMR technique
seemed to be more favorable than that of onlays placed on teeth
without margin relocation, especially in the presence of higher
loads and more eccentric forces.6 Other investigators evaluat-
ing the effect of CMR on marginal quality found that, for deep
agd.org/generaldentistry e1
Effect of cervical margin relocation technique with composite resin on the marginal integrity of a ceramic onlay: a case report
Fig 1. Preoperative views of the carious maxillary and mandibular right first molars.
Fig 2. Periapical radiographs following endodontic treatment
of the maxillary and mandibular right first molars.
proximal boxes ending in dentin, CMR may be an alternative to
more traumatic conventional techniques such as surgical crown
lengthening or orthodontic extrustion.7,8
Zaruba et al, using a margin elevation technique, found that
the marginal integrity of ceramic inlays placed after composite
resin restoration of the proximal box was comparable to that of
ceramic inlays placed in dentin.9 However, Spreafico et al evalu-
ated the effects of CMR with composite resin restorations on
the marginal quality of crowns fabricated via computer-aided
design/computer-assisted manufacturing and found that CMR
had no effect on cervical marginal quality.10 They suggested that
more studies needed to be conducted to confirm whether CMR
is a suitable procedure for adhesive luting of composite resin
crowns in deep proximal boxes.10
Many dental clinicians have used CMR techniques clinically,
and multiple published clinical reports have shown promising
results.1-5,11-13 The present case report details the use of CMR for
management of a mandibular first molar with a deep carious
lesion.
Case report
A 45-year-old woman was referred to the Comprehensive
Dental Treatment Clinics at the College of Dentistry, King Saud
University, Riyadh, Saudi Arabia, for replacement of defective
restorations due to extensive recurrent caries. A thorough case
evaluation was done, and a treatment plan was formulated.
Both the maxillary and mandibular right first molars had
large distal carious lesions and necrotic pulps, and both were
diagnosed with symptomatic apical periodontitis (Fig 1). Root
canal treatment was performed for both teeth (Fig 2). For the
e2 GENERAL DENTISTRY July/August 2020
Fig 3. Postoperative views of the maxillary right first molar, restored with
a zirconia crown, and the mandibular right first molar, restored using
cervical margin relocation and a ceramic onlay.
maxillary molar, a crown-lengthening surgical procedure was
performed after endodontic treatment was completed. To avoid
jeopardizing the furcation area, only a small amount of bone
was removed. After 6 weeks of healing, the new bone level was
reassessed and found to be satisfactory.
For the mandibular molar, a minimal crown-lengthening pro-
cedure was performed after root canal therapy. After evaluating
the results of the procedure when the site was healed, the clini-
cian decided to employ a conservative CMR technique because
crown lengthening to the extent of the carious lesion would
have exposed the furcation, compromising the prognosis. Under
rubber dam isolation, the temporary restoration was removed,
a properly adapted matrix band (No. 2 Tofflemire matrix band
for deep cavities) was applied, and a complete seal was ensured.
Composite resin (Tetric N-Ceram Bulk Fill, Ivoclar Vivadent)
was used as a base. The composite was condensed in the proxi-
mal box after etching and bonding according to the manufactur-
er’s instructions. The resin was placed in 2 increments, and each
increment was light-cured separately. The total elevation of the
margin (thickness) was 1.5 mm. A postoperative bitewing radio-
graph was taken to confirm the continuity of the margins. Then
the prosthodontic treatment was completed using a composite
core build-up and ceramic onlay. The maxillary molar received
a prefabricated fiber post, composite core build-up, and zirconia
crown (Fig 3). The satisfactory outcome suggested a promising
prognosis for the oral health of the patient.
Discussion
Prior to restoration of an endodontically treated tooth, it is
essential to assess the amount of remaining tooth structure
and the extension of the carious lesion to the bone crest.2
Traditionally, a minimum of 3 mm of vertical distance between
the restoration margins and the alveolar bone crest (biologic
width) is required to maintain gingival health.14,15 Violation of
the connective tissue with a restoration will lead to inflamma-
tion and subsequent bone resorption.16
In 2012, Magne & Spreafico proposed the CMR technique
(deep margin elevation) as a noninvasive alternative to crown
lengthening.3 Using this technique, the deep cervical margin can
be elevated with composite resin to facilitate isolation with a
rubber dam, marginal preparation, impression-making, and easy
removal of excess cement from an indirect restoration.3
Cases selected for CMR must meet 3 criteria: the ability to
establish complete isolation of the operative field; the ability
to place a matrix band in a way that ensures a perfect seal; and
the ability to position the matrix so that it does not violate the
connective tissue space.2 Otherwise, crown lengthening or orth-
odontic exposure of the tooth should be considered.17,18
The present case was managed by conducting both a conser-
vative CMR technique and a crown-lengthening procedure for
different teeth in the same patient. A thorough examination and
assessment of the case was carried out to formulate the best
treatment for each tooth. An indirect restoration that reached
the tooth margin could not be fabricated for the mandibular
right first molar because crown lengthening to that level would
have exposed the furcation. An alternative treatment option
would have been to extract the tooth and replace it with an
implant-supported crown. However, since the primary goal in
dentistry is to preserve remaining tooth structure, the CMR
technique was chosen because it is a noninvasive and conserva-
tive approach for the management of extensive carious lesions.
Conclusion
Cervical margin relocation is a noninvasive and conservative
approach for facilitating restoration of teeth with deep gingival
cavity margins. Whenever the anatomy permits the placement
of a matrix band to ensure absolute gingival isolation and pre-
dictable placement of a composite resin base, CMR can be per-
formed. However, treatment of deeper margins that invade the
connective tissue or the bone crest should be approached with
crown-lengthening surgery or other modalities.
Author information
Dr Alhassan is a recent graduate, College of Dentistry, King
Saud University, Riyadh, Saudi Arabia, where Dr Bajunaid is an
associate professor, Department of Prosthetic Dental Science.
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Acknowledgments
The authors would like to thank the College of Dentistry
Research Center and Deanship of Scientific Research at King
Saud University for supporting this project.
Disclaimer
The authors report no conflicts of interest pertaining to any of
the products or companies discussed in this article.
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