3 PROXIMAL BOX ELEVATIONAND BIOLOGICAL WIDTH CLINICAL R2 TECHNIQUE Frese2013

 

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Operative Dentistry, 2014,  39-1,  39-1, 22-31  22-31

Proximal Box Elevation With Resin Composite and the Dogma of Biological Width: Clinical R2-Technique and Critical Review C Frese     D Wolff     HJ Staehle

Clinical Relevance  Advancements in material technology and clinical techniques led to increasing indications for minimally invasive treatment approaches with direct resin compo composite site restorations. 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.

SUMMARY Provided Provid ed tha thatt moi moist sture ure con contro troll is pos possib sible, le, today’ tod ay’s s res resin in com compos posite ite mate materia rials ls can be applied successfully in the of ex exten tensi sivel vely y dec decaye ayed d restorative teeth. tee th. Thi This streatment sugge sug gests sts that res restora torativ tive e marg margins ins wil willl be inc increa reasin singly gly locate loc ated d bel below ow the cem cement entoen oename amell jun juncti ction, on, probabl pro bably y inv invadi ading ng bio biolog logica icall wid width. th. The re*Cornelia *Corneli a Fres Frese, e, Dr. med. dent., seni senior or dent dentist, ist, Univ Universi ersity ty Hospital Heidelberg, Department of Conservative Dentistry, Heidelberg, Germany Diana Wolff, Dr.med.dent, University of Heidelberg, Department of Conservative Dentistry, Heidelberg, Germany Hans Joe Hans Joerg rg Sta Staehl ehle, e, Pro Prof.D f.Dr.m r.med. ed.,, Dr. Dr.med med.de .dent. nt.,, hea head d of  departme depa rtment, nt, Unive University rsity of Hei Heidelb delberg, erg, Depa Departme rtment nt of Conservative Dentistry, Heidelberg, Germany *Corresponding author: Im Neuenheimer Feld 400, Heidelberg, 69120, German Germany; y; e-mail e-mail:: corneli cornelia.fres a.frese@med. [email protected] DOI: 10.2341/13-052-T

cently int cently introd roduced uced tec techni hnique que of pro proxima ximall box elevati ele vation on (PBE (PBE)) offe offers rs the pos possib sibili ility ty of per per-forming a stepwise elevation of deep proximal cavities to create more favorable preparation margi mar gins ns for di direc rectt or ind indir irec ectt re resto storat ratio ions. ns. Clinic Cli nical al ins instru tructi ctions ons for the res restor torati ation on of  extensively damaged teeth are given through this presentation. A two-step R2-technique will be shown, and a critical review of the dogma of  biological width will be presented. INTRODUCTION With cur With curre rent nt adh adhesi esive ve tec techno hnolog logy y and mod modern ern composite resin materials it has become possible to restor res tore e eve even n sev severe erely ly dam damage aged d tee teeth. th. Thu Thus, s, min miniimall ma lly y in inva vasi sive ve te tech chni niqu ques es ar are e us used ed to sa save ve a maximum amount of sound tooth substance. 1 Even extens exte nsive ive an and d un unde derm rmin ining ing to toot oth h de defe fect ctss ca can n be restored resto red using direct compos composite ite resin mater materials. ials. In general, it is recommended that the cervical margin

 

Frese, Wolff & Staehle: Proximal Box Elevation and the Dogma of Biological Width 

 

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of the restoration should be placed within an intact enamel ena mel lay layer. er. Ho Howev wever, er, pro provid vided ed tha thatt moi moistu sture re control is possible, composite resin restorations can be applied successfully in deeper cavities, even when restorative margins are located below the cementoenamel junction (CEJ).2  A new operational range is thus th us ope opene ned d up as th the e co comp mpos osit ite e re resi sin n is lo loca cate ted d

deep occlus occluso-prox o-proximal imal resin compos composite ite restor restoration ationss invadi inv ading ng bio biolog logica icall wid width th are fre free e of gin gingiv gival al and periodo per iodonta ntall inf inflam lammat mation ion,, pro provid vided ed tha thatt ther there e is distinct oral hygiene training and use of accurately fitting fit ting inte interde rdenta ntall bru brushe shes. s. Thi Thiss fac factt lea leads ds to the hypothesis that subgingival composite resin restorations fabricated using a two-step R2-technique may

subgingivally adjacent to the junctional epithelium and alv alveol eolar ar bon bone e cre crest. st. Mod Modern ern app applic licati ation on tec techhniqu ni ques es al allo low w fo forr the cr crea eati tion on of pla plann nned ed an and d 3,4 nonirritating composite resin margins in this area.  A recently described technique, proximal box elevation ti on (P (PBE BE), ), of offe fers rs th the e pos possi sibi bili lity ty of a st step epwi wise se relocation of deep proximal margins to uplift cavity outlines outlin es for direct or indire indirect ct resto restoration rations. s.5,6 Step one (PBE) involves a meticulous layering technique for margin relocation above the CEJ. Step two allows the th e pr prac acti titi tione onerr to de deci cide de on wh wheth ether er to pl plac ace e a direct or indirect restoration under improved clinical conditions.

violate the area of biological violate biological width without inducing chronic inflammation.

Before Bef ore res restor toring ing ext extens ensive ively ly dec decaye ayed d tee teeth, th, the distance between future restorativecarefully, margin and the alveolar crest the should be evaluated for example, by bone sounding. An adequate space for restor res torati ative ve mar margin gin pla placem cement ent can be ach achiev ieved ed by surgical (crown lengthening procedure) or orthodontic treatme treatment nt (forc (forced ed eruptio eruption). n).7 The physio physiologica logicall dimens dimensions ions of the dentog dentogingiva ingivall  junction, with its inherent parts of epithelial attachment, men t, con connec nectiv tive e tis tissue sue att attach achmen ment, t, an and d sul sulcus cus depth, were first described by Gargiulo and others in 19618 and reevaluat reevaluated ed by Vac Vacek ek and others others in 9 1994. Ga Garg rgiu iulo lo an and d ot othe hers rs de desc scri ribe bed d the id idea eall dimens dim ension ion of the den dentogi togingi ngival val junc junctio tion n to be 2.7 2.73 3 mm and Vacek and others determined it to be 3.25 mm.9 Based on these reports, a distance of 3 mm and more is recommended between restorative margins and the alveolar crest to avoid detrimental effects on neighboring soft and hard tissues.10-13 In restorative terminology this distance is generally called ‘‘biological width.’’  Violations of the biological width resulting from intracrevicular placement of restorative margins can result res ult in sev sever ere e gin gingiv gival al inf inflam lammat mation ion,,4 lo loss ss of  period per iodonta ontall atta attachme chment, nt, and bon bone e res resorp orptio tion. n.11,15 Furthe Fur thermo rmore, re, ma margi rginal nal ove overha rhangs ngs of dir direct ect and indirect restorations are related closely to elevated plaque accumulation, microbiological diversification, and increasing chronic inflammation of soft and hard tissue.16 Clinical observations in our department revealed thatt pla tha plain, in, smo smooth, oth, and non nonirr irrita itatin ting g mar margins gins on

Togeth Tog ether er wit with h the cli clinic nical al pro proced cedure ure pre presen sented ted here,, a st here step epwi wise se in intr trod oduc ucti tion on is gi give ven n to th the e restoration of extensively damaged teeth by applying a direct composite resin restoration, using the twostep R2-technique (step one: PBE; step two: direct composite resin restoration). Furthermore, a critical review is given on the consistency of the dogma of  biological width.

CLINICAL TECHNIQUE Patient Presentation  A 75-year-old female psychologist visited the Department partme nt of Conse Conservativ rvative e Dentis Dentistry, try, Clinic for Oral, Dental and Maxillofacial Diseases, University Hospita pi tall He Heide idelb lber erg, g, wi with th a res resto tora rati tion on lo loss ss on th the e mand ma ndib ibul ular ar ri righ ghtt pr prem emol olar ar #4 #45. 5. A re revi view ew of he herr medical history revealed no medical disease. She was a non nonsmo smoker ker and too took k no med medica icatio tions. ns. She sta stated ted that she felt no pain on tooth #45. Clinical examination revealed positive vitality, no tooth mobility, and probing depths of 2 mm. Intraoral evaluation revealed carious decay on the cervical cervic al mar margin gin of the cav cavity ity rea reachi ching ng bey beyond ond the CEJ.. The pro CEJ proxim ximal al mar margin gin wa wass par partly tly cov covere ered d by overgrowing gingival tissue (Figure 1). Radiographic examination of tooth #45 revealed that there was no periap per iapica icall tra transl nsluce ucency ncy and tha thatt the dis distanc tance e between the cavity margin and the alveolar bone crest was between 0.5 mm and 1.0 mm (Figure 2). As the proximal cavity margin was already beyond the CEJ invading biological width, it was assumed that after caries removal it would be located at the level of the alveolar crest. It was explained to the patient that the gold-standard treatment would be placement of  an indirect partial or full crown in combination with surgical surgi cal or ortho orthodontic dontic pretre pretreatment. atment. Alter Alternative natively, ly, it was clarified that if the marginal ridge was still intact int act,, a dir direct ect res restora toratio tion n wit with h com compos posite ite res resin in could be an option. However, it was also explained thatt the outcome tha outcome of this pro proced cedure ure would be les lesss predictable than that of an indirect restoration. The patient favored a restoration with direct composite resin to avoid surgical or orthodontic interventions.

 

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Operative Dentistry 

Table 1:  Table of materials used for R2-technique  Material

Figure 1. Pre Figure Preope operat rative ive vie view w of too tooth th #4 #45 5 wit with h occ occlus luso-p o-pro roxim ximal  al  decay and loss of restoration a few weeks before R2-technique was  performed perfo rmed.. Ging Gingival ival overgrowth overgrowth is seen on prox proximal imal cavity marg margin  in  (arrow) .

Description of the R2-Technique Ste Step p One (PBE) (PB E)—Al —All l mat materi erials als used are listed in Table 1. After local anesthesia, the excessive gingiva was rem remove oved d usi using ng an ele electro ctrosur surgic gical al uni unitt (El (Elekektrot tr otom om MD 62 62,, KLS Ma Mart rtin in Gm Gmb bH & Co KG KG,, Tuttlingen, Tuttli ngen, Germany). Germany). Carie Cariess was removed with a bur (H1 (H1SEM SEM 204 204.01 .018-2 8-23, 3, Kom Komet, et, Geb Gebr. r. Bra Brasse sseler ler GmbH & Co.KG, Lemgo, Germany), and any sharp

Electr Ele ctrosu osurgi rgica call un unit it

Elektroto Elektr otom m MD 62, KLS Mar Martin tin Gm GmbH bH & Co KG, Tuttlingen, Germany

Rotary instruments H1SEM 204.018-23 204.018-23,, #128-130

Komet, Gebr. Brasseler GmbH & Co.KG, Lemgo, Germany

Astringent retraction paste

Astringent Retraction Paste, 3M ESPE, Sefeld, Germany

Adhe Ad hesi sive ve sy syst stem em

Opti Op tibo bond nd FL FL,, Ke Kerr rr,, Or Oran ange ge,, CA CA,, US USA A

Flowab Flo wable le com compos posite ite

Tetric Ev Tetric Evo o Flo Flow, w, Ivo Ivocla clarr Viv Vivade adent, nt, Schaan, Liechtens Liechtenstein tein

Restorative resin composite

Tetric Evo Ceram, Ivoclar Vivadent, Schaan, Liechtens Liechtenstein tein

Rubber dam

Hygienic Dental Dam, Coltene Whaledent, Langenau, Germany

50   lm Al2O3   pow powder der

Kaltenba Kalte nbach ch & Vo Voigt igt,, Bib Bibera erach ch,, Germany

Sectiona Sect ionall matrix system system

Palodent, Dentsp Palodent, Dentsply ly DeTrey, DeTrey, Konstanz, Konstanz, Germany

Proximal contact instrument

OptraContact, Ivoclar Vivadent, Schaan, Liechtens Liechtenstein tein

Poli Po lish shin ing g ki kitt

Astr As trop opol ol HP HP,, Iv Ivoc ocla larr Vi Viva vade dent nt,, Sc Scha haan an,,

Inte In terd rden enta tall br brus ush h

 

Manufacturer

Liechtenstein CPS 14 Z, Cu CPS Cura rade den n In Inte tern rnat atio iona nall AG AG,, Amlehnstrasse 22, 6010 Kriens, Schweiz

angles were rounde rounded. d. At this point, it was clear that the proximal cavity margin was close to the alveolar crest, making the application of a partial or circular matri ma trix x imp impos ossi sibl ble e (F (Fig igure ure 3) 3).. For he hemos mostas tasis is,, a retraction cord was placed and an astringent paste wass ap wa appli plied ed fo forr 2 mi minut nutes es an and d rin rinse sed d ca care reful fully ly (Astri (As tringe ngent nt Ret Retrac raction tion Pas Paste, te, 3M ESP ESPE, E, See Seefel feld, d, Germany) Germa ny) (Figu (Figure re 4). After Afterward, ward, direct compos composite ite resin was applied to perform a PBE in accordance with the protocol of Frankenberger and others 5 and Roggendorf and others   6 (Figure 5). Tooth #45 was etched for 15 seconds with 37% phosphoric acid, a filled ethanol-based adhesive system (Optibond FL, Kerr Ke rr,, Or Oran ange ge,, CA CA,, US USA) A) wa wass ap appl plie ied d an and d th the e adhesive was light-polymerized for 20 seconds (Bluephace C8, Ivoclar, Vivadent, Schaan, Liechtenstein).  A thin layer of flowable composite resin (Tetric Evo Flow, Flo w, Ivo Ivocla clarr Viv Vivade adent) nt) was placed placed on the cav cavity ity marg ma rgin in.. On to top p of th the e no nonp npol olym ymer eriz ized ed la laye yerr of  flowab flo wable le res resin, in, ano anothe therr lay layer er of vis viscou couss com compos posite ite resin re sin wa wass ap appli plied ed (T (Tetr etric ic Ev Evo o Ce Cera ram, m, Iv Ivoc ocla larr  Vivadent). The viscous material was molded and gently pressed into the flowable resin (Snowplough Techniq Tec hnique, ue, Fig Figure ure 6 det detail ailed ed des descri criptio ption n vid vide e in17

Figure 2. Preoperative x-ray of tooth #45. After excavation of caries, the pro proxim ximal al cav cavity ity mar margin gin is loc locate ated d clo close se to the alv alveol eolar ar cre crest  st  (arrow) .

fra). Final polymerization polymerization of both the flowa flowable ble and the viscous composite resin was then completed with light lig ht at 800 mW/cm mW/cm2 (40 seconds). seconds). Bec Becaus ause e of the

 

Frese, Wolff & Staehle: Proximal Box Elevation and the Dogma of Biological Width 

Figure 3. R2Figure R2-tec techn hniqu ique: e: Pla Placem cement ent of a dir direct ect res resin in com compos posite  ite  restor res torati ation on in the two two-st -step ep tec techni hnique que.. Ste Step p one (PB (PBE): E): Cli Clinic nical  al  situation after gingivectomy (Elektrotom) and caries excavation. The  proximal cavity margin is located below the CEJ next to the alveolar  crest .

abandonment of a matrix, marginal overhangs could not be avo avoide ided. d. Sub Subseq sequen uently tly,, the they y wer were e rem remove oved d carefully caref ully with a rotar rotary y diamo diamond nd instru instrument ment #128130 13 0 (Fl (Flamm amme e 128 128-1 -130; 30; Kom Komet, et, Ge Gebr. br. Bra Brasse sseler ler GmbH & Co.KG) and a scalpel (Figure 7a). Step Two (di Step (direc rectt com compos posite ite res resin in res restor toratio ation) n)—A  —A  rubber dam (Hygienic Dental Dam, Coltene Whaledent, de nt, La Lang ngen enau, au, Ge Germa rmany ny)) wa wass pla placed ced,, an and d th the e previo pre viousl usly y pla placed ced PBE was cle cleane aned d car carefu efully lly and

Figure 4. Ap Figure Appli plicat cation ion of a ret retrac ractio tion n cor cord. d. The cord could could not be  inserted fully into the sulcus because of the proximity of the alveolar  crest. Subsequently, an astringent paste was applied for 2 min .

 

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Figure 5. Afte Figure Afterr etching, etching, priming, priming, and bonding, bonding, a laye layerr of flow flowable  able  composite was placed meticulously on the cavity margin, followed by  a lay layer er of vis viscou cous s res resin in com compos posite ite (bo (both th unp unpoly olymer merize ized). d). Aft After  er  modeling mode ling and shap shaping ing both materials, materials, the final light poly polymeriz merizatio ation  n  was carried out (Snowplough technique) .

roughened by Al2O3   powder (50   lm,   Kaltenbach &  Voigt,  Voig t, Bibe Biberach, rach, Germ Germany). any). A secti sectional onal matr matrix ix (Palodent, (Palo dent, Dentsp Dentsply ly DeTr DeTrey, ey, Konsta Konstanz, nz, Germa Germany) ny) w as as in inss ert erte e d a nd nd f ix ix ed ed w ith ith a w edg edge e a nd nd a separa sep aratio tion n rin ring. g. Bet Betwee ween n the PBE placed placed in ste step p one and the sectional matrix, a narrow and sharp angled angle d junctio junction n occur occurs. s. Etchin Etching g and bonding steps were carried out using the same materials described previously.

Figure 6. Schematic drawing of Snowplough Snowplough technique: Note that that in  clinical practice there is a narrow and sharp angled junction between  PBE placed in step one and the sectional matrix .

 

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Operative Dentistry 

Figure 8 .   Com Figure Compos posite ite res resin in is app applie lied d usi using ng the Sno Snowpl wploug ough  h  techniq tec hnique. ue. To obt obtain ain a tig tight ht pro proxim ximal al con contac tact, t, a spe specia ciall han hand  d  instrument was used to separate the teeth during light polymerization .

To obtain a tight proximal contact, a special hand

Figure 7 .   (a) Cli Figure Clinic nical al sit situat uation ion aft after er the PB PBE. E. Th The e su subgi bgingi ngival  val  restorative margin was finished with rotary diamond instruments and  a scalpel to remove overhangs and to create a smooth, planed, and  nonirritating surface. (b) Step two: Occlusal view after application of  the rubb rubber er dam, subs subsequ equent ent sand sandblas blasting ting with alum aluminium inium oxide, place pla ceme ment nt of a sec sectio tional nal mat matrix rix,, we wedgi dging, ng, and ap appli plica catio tion n of a  separation ring .

ins instru trumen mentt (Op (Optra traCon Contac t, Ivo Ivocla clarr Viv Vivade adent) nt) was used (Figures 8 and 9). tact, Final polymerization of both the flo flowab wable le and the vis viscou couss com compos posite ite res resin in was then the n co compl mplet eted ed wi with th lig light ht at 80 800 0 mW mW/c /cm m2 (40 seconds). Finally, the rubber dam was removed, the occlu oc clusio sion n wa wass ch check ecked, ed, an and d th the e res resto tora ratio tion n wa wass fini fi nish shed ed us usin ing g the As Astro tropo poll HP Fi Finis nishin hing g Ki Kitt (Astropol HP, Ivoclar Vivadent) (Figures 7b through 10). After the treatment session, the patient underwentt ora wen orall hyg hygien iene e tra traini ining, ng, and acc accura urately tely fit fitting ting interdental brushes were chosen (Figure 11).

The composite resin was applied using the Snowplough technique (Figure 6).  A small amount of flowable composite resin (Tetric Evo Ev o Fl Flow ow,, Iv Ivoc ocla larr Vi Viva vade dent) nt) wa wass ap appl plie ied d on the bottom bot tom of the cavity cavity and gently gently dis disper persed sed with a dental den tal pro probe be for non nonpor porous ous ada adapta ptatio tion. n. The non non-polymerized polym erized flowable flowable resin should cover the sharp angle an gled d jun juncti ction on be betw tween een th the e ca cavit vity y ma margi rgin n an and d sect se ctio iona nall ma matr trix ix co comp mple lete tely ly.. On to top p of th the e no nonnpolymerized layer of flowable resin, small amounts of  viscou vis couss com compos posite ite res resin in wer were e app applie lied d (Te (Tetric tric Evo Ceram, Ivoclar Vivadent) and gently pressed into the flowable flow able resin using a hand instrument. instrument. In this way, the composite resin was adapted tightly to the cavity surface, resulting in a nonporous restoration–tooth interface.

Figure 9. Oc Figure Occlu clusal sal view aft after er rem remova ovall of the proximal proximal contact  contact  instru ins trumen ment. t. A tig tight ht pro proxim ximal al con contac tactt to the adj adjace acent nt too tooth th is  accomplished .

 

Frese, Wolff & Staehle: Proximal Box Elevation and the Dogma of Biological Width 

 

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Figure Figu re 10. Clin Clinical ical situatio situation n after removal removal of the rubber dam .

The pos postope toperati rative ve rad radiog iograph raphic ic exa examina mination tion of  tooth #45 revealed that the proximal cavity margin was located adjacent to the alveolar bone crest and in clos cl ose e co cont ntac actt to co conn nnec ectiv tive e tis tissu sue e fi fibr bres es of the dentogingival complex (distance 0.5–1.0 mm) (Figure 12). 12-Month Recall—The Recall—The clinical observation after 12 months revealed a vital tooth #45 with no inflammatory signs in the surrounding soft and hard tissue (Figure 13). Despite the fact that the biological width was clearly violated, the probing depths were 2 mm, and no ble bleedi eding ng occ occurr urred ed on pro probin bing g (Fi (Figur gure e 14) 14).. Radiographic examination revealed a distance of 1 mm between the restorative margin and the alveolar Figure Figur e 12. Po Post stope opera rativ tive e x-r x-ray ay of too tooth th #45 #45.. The su subg bging ingiv ival  al  restorative margin invades the biological width (the distance between  restor res torati ative ve mar margin gin and alv alveol eolar ar cre crest st was 0.5 0.5–1. –1.0 0 mm) mm).. The  emergen eme rgence ce prof profile ile of the dire direct ct comp composit osite e resi resin n rest restorat oration ion is  anatomically correct. The first part of the R2-restoration (PBE) merges  anatomically continuously into the second part of the restoration 

crest. Over the 12-month period, only a minima crest. minimall loss of alveolar bone was observed (Figure 15).

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 ste step p of the presente presented d two two-st -step ep R2- technique, the complex problem of moisture management and res restora toratio tion n acc accomp omplis lishme hment nt is red reduce uced d to the Figure 11. 11. Postoperativ Postoperative e view showing showing the selection of an accurately  accurately  fitting interdental brush .

circums circ umscr crib ibed ed ar area ea of th the e pr prox oxim imal al bo box. x. In thi thiss comparatively small area of the tooth, contamination is easier to handle and prevent, even if no rubber

 

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Operative Dentistry 

Figure Figu re 13. Clini Clinical cal situation situation after after 12 months: months: occlusal occlusal view .

dam is placed. After this critical part of the cavity is taken care of separately, a rubber dam can be placed much easier in step two of the restorative procedure, as described previously.5 The Snowplough technique contributes essentially to achieving a homogenous and nonporous restoration–tooth interface. It is described as the combined use of a flowable composite and a viscous composite resin res in mol molded ded tog togeth ether er in an unp unpoly olymer merize ized d sta state, te, follow fol lowed ed by fin final al pol polyme ymeriz rizatio ation n of bot both h mat materi erials als 17 (Figure 6).

Figure 15. Radi Figure Radiogra ograph ph of tooth #45 after 12 months. Radiogra Radiographic  phic  examination revealed a distance of 1 mm between the restorative  margin and the alveolar crest. Minimal loss of alveolar bone can be  observed after 12 months (arrow) .

In the clinical case presented, the occluso-proximal restoration margin was located below the CEJ and invaded invade d the biolo biological gical width. Howe However, ver, no adver adverse se reactions, such as chronic inflammation of soft and hard har d tis tissue sues, s, att attach achmen mentt los loss, s, or bon bone e res resorp orption tion,, were observed at the 12-month follow-up. The pri princip nciple le of bio biolog logica icall wid width th sug sugges gests ts that severe sev erely ly dam damage aged d tee teeth th res resulti ulting ng fro from m tra trauma uma or cariess shoul carie should d be pretre pretreated ated surgically surgically or ortho orthodontidonticall ca lly y to ga gain in an ad adeq equa uate te sp spac ace e of su supr prac acre rest stal al,, sound, hard tissue.18,19 In contrast to the anatomically defined area of the dentogingival junction, the dimension dimens ion of the biological biological width is defin defined ed based on several clinical studies and the opinion of experts. 20 Obligatory values do not exist because of individually differing characteristics of gingival morphology, the width of the keratinized gingiva, and periodontal condition.15

Figure 14. Bucc Figure Buccal al view after after 12 months. months. The probing probing pocket pocket depths  in the proximal area were 2 mm, and no bleeding occurred on probing .

 All radiographs of the presented case were taken using the longlong-cone cone parallel technique technique with Rinn’s film holders to achieve utmost accuracy and minimal

 

Frese, Wolff & Staehle: Proximal Box Elevation and the Dogma of Biological Width 

distortion.7  At the 12-month follow-up, the radiographic examination revealed a distance of 0.5–1.0 mm between the restorative margin and the alveolar crest with no signs of clinical inflammation.

How Can These Clinical Observations Be Explained With the Current Literature? Restorati Restor ative ve mar margin ginss com comple pletel tely y sur surrou rounde nded d by sound enamel are an ideal situation for structural conservation of surrounding soft and hard tissues. 21 Extens Ext ensive ive and und underm erminin ining g car cariou iouss les lesion ionss or severe sev ere tra trauma uma oft often en pro provid vide e the pos possib sibili ility ty of  placin pla cing g res restor torati ative ve mar margin ginss in so sound und ena enamel mel..  Additionally,  Addition ally, the degree of difficul difficulty ty in placing deep subgingiva subgi ngivall restor restorations ations increa increases ses drama dramaticall tically y becau be cause se of inf inferi erior or ins insigh ightt int into o and acc access ess to the cavity cav ity,, lea leadin ding g to pro proble blemat matic ic mar margin ginal al con contro trol, l, managemen mana gementt of under underminin mining g area areas, s, and moist moisture ure control. In a literature review, Brunsvold and Lane22 could show that the prevalence of marginal overhangs was

 

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lamina under the influence of fibrin.24 It is known thatt epi tha epithe thelia liall att attach achmen mentt is not spe specif cific ic for one surface structure. It is capable of being formed on enamel, cementum, afibrillar cementum, and cuticle.24

Is Reattachment During Wound Healing on a Plain Resin Composite Surface Possible? On the bas basis is of our cli clinic nical al obs observ ervati ations ons,, it is not possib pos sible le to dra draw w any con conclu clusio sions ns abo about ut epi epithe thelia liall reatta rea ttachm chment ent on a pla plain in res resin in com compos posite ite sur surfac face. e. However, Howe ver, a noninf noninflamma lammatory tory rehab rehabilitat ilitation ion of soft and hard tissue next to deep proximal cavities after PBE can be achieved with the clinical R2-technique presented here. In res restor torati ative ve den dentis tistry try,, the sea search rch for an ide ideal al material to restore the apical part of deep proximal cavi ca vitie tiess is no nott new new.. Gl Glas asss io iono nome merr ce cemen ments ts,,25,26 1,27 polyacid-mo polya cid-modified dified resin compos composite ite materi materials als and composite compos ite resin syste systems ms2 are dis discus cussed sed int intens ensely ely regarding their role in long-term durability. Yet with

between betwe en 25 25% % an and d 76 76% % in all re resto stored red su surf rface aces. s. Subging Sub gingiva ivall res restor torativ ative e mar margin gins, s, and esp especia ecially lly marginal overhangs, contribute to plaque accumulation, tio n, chro chronic nic inf inflam lammati mation, on, att attach achment ment los loss, s, and 20,22 bone resor resorption. ption. Molarss restor Molar restored ed with indirect crowns cro wns or dire direct ct occl occlusouso-prox proximal imal rest restorat orations ions showe sho wed d inc increa rease sed d inv involv olveme ement nt of the fu furca rcatio tion n 23 compar com pared ed wit with h sou sound nd mol molars ars.. Furthermore, 16 Flores-deFlore s-de-Jacob Jacoby y and others reported report ed increa increased sed amount amo untss of spi spiroc rochet hetes, es, fus fusifo iforms rms,, rod rods, s, and fil filaamentous bacteria in subgingival plaque. However, no association was found between restorative margins belo be low w the CE CEJ J an and d the oc occu curre rrenc nce e of se seco cond ndar ary y caries.2

increa incr ease sed d de degr gree ee of dif diffi ficu cult lty, y, the there re ar are e so some me substa sub stanti ntial al fac factor torss inf influe luencin ncing g the lon long-t g-term erm out out-come of a restoration substantially below the CEJ. The individual skills of the operator 28 or the degree of contamination with blood or saliva29 are prone to the development of secondary caries and/or failure of  a restoration.

 A poss possible ible expl explanat anation ion for the soun sound d peri periodon odontal tal and gingival condition in the presented case may be the polished, planed, and nonirritating subgingival margin, which was created during the first step (PBE) of the R2-technique. This, in combination with the dist distinct inct oral hygi hygiene ene protocol, protocol, the individua indi vidually lly adap adapted ted inter interdenta dentall brus brushes, hes, and their adequate and regular use, may have contributed to the clinical success at the 12-month followup.

mainly main ly de desi signa gnate ted d fo forr bu buil ildi ding ng up on only ly pa part rtss of  teeth, here proximal areas. It is assumed that the violat vio lation ion of the bio biolog logica icall wid width th wit within hin a lim limited ited extent ext ent,, und under er the pre precon conditi dition on of sup superi erior or ora orall hygien hyg iene, e, can be suc succes cessfu sful. l. Fur Furthe therr exp experi erimen mental tal and clinical research should be encouraged to gain further information on relevant questions, such as the tol tolera erable ble ext extent ent of vio violat lation ion of the bio biolog logica icall width,, favo width favorable rable materials materials in the subgingival subgingival area and an d th thei eirr lo long ng-t -ter erm m bo bond nd st stre reng ngth th an and d su surf rfac ace e characteristics, and the evaluation of patient characteristics.

We a ss ss ume ume th tha a t du duri ring ng w oun ound d he hea a lin ling g an epitheliall reatt epithelia reattachme achment nt may have take taken n place on both bo th th the e ce ceme ment ntum um an and d th the e ap apic ical al pa part rtss of th the e composite comp osite resi resin n surf surface. ace. After iatrogenic iatrogenic detac detachhment resulting from surgical or restorative procedures, dur es, wo wound und hea healin ling g tak takes es pla place, ce, inv involv olving ing hemidesmosomes and the restructuring of the basal

However in recent years, several new techniques, for example the PBE,5,6 the elastic cavity wall,3,4 and the Snowplough technique17 (Figure 6) were developed to increase clinical sucess in managing difficult situat sit uation ions. s. The They y pro provid vide e pro promis mising ing app approa roache chess to manage manag e comple complex x direct resin resto restoration rationss on sever severeely decayed teeth. Remarkably, these techniques are

CONCLUSION  Advantages 1. The two two-st -step ep R2R2-tec techni hnique que (st (step ep one one:: PBE PBE;; ste step p two: direct composite resin restoration) provides

 

 

30

an additional treatment option for the restoration of deep and undermining cavities reaching below the CEJ. 2. Disti Distinct nct oral hygiene training (including (including the use of ac accu cura rate tely ly fi fitt tting ing in inte terde rdent ntal al br brush ushes es)) in patients patien ts with occlus occluso-prox o-proximal imal resto restoration rationss invading the biological width is necessary to achieve clinical situation. 3. a It noninflammatory is ass assume umed d tha thatt the extent extent of biologic biological al width violation plays a role in the biological reaction of  soft so ft an and d ha hard rd ti tiss ssue ues: s: li limi mited ted pr prox oxima imall ar area ea versus complete circumferential margin.

Disadvantages 1. The The typ type e of re rest stor orat atio ion, n, ma mate teria rials ls us used ed,, an and d marginal quality are determining factors in the clinical performance of restorations invading the biological biolo gical width (dire (direct ct versu versuss indire indirect ct restor restoraations). 2. The reasons for individual individual variations variations in biolo biological gical response to restorations below the CEJ that are invading biological width are yet unknown. 3. The There re is no evidence evidence in the literatu literature re about the long-term bond strength and marginal quality of  two-step composite resin restorations. Conflict of Interest The authors authors of thi thiss man manusc uscrip riptt cer certif tify y tha thatt the they y hav have e no proprietary, financial, or other personal interest of any nature or kin kind d in any product, product, ser servic vice, e, and and/o /orr com compan pany y tha thatt is presented in this article.

(Accepted 26 March 2013) References 1. Dietrich Dietrich T, Kraemer M, Losche GM, & Roul Roulet et J (200 (2000) 0) Marginal Margi nal integrity integrity of large compomer compomer Clas Classs II rest restoraoraJournal of  tions tio ns wit with h ce cervi rvical cal ma margi rgins ns in de denti ntine ne   Journal  Dentistry  28(6)  399-405.

2. Kuper NK, Opdam NJ, Bronkhorst Bronkhorst EM, & Huysmans Huysmans MC (2012) The influence of approximal restoration extension Journal of  on the dev devel elopm opment ent of sec secon ondar dary y car caries ies   Journal  Dentistry  40(3)  241-247. 3. Cavalcanti AN, Mitsui FH, FH, Ambrosano GM, & Marchi Marchi GM (2007) (200 7) Inf Influe luence nce of adhe adhesive sive syst systems ems and flo flowabl wable e composite lining on bond strength of Class II restorations submitted to thermal and mechanical stresses  Journal of   Biomedical Materials Research. Part B, Applied biomaterials  80(1)   52-58.

Operative Dentistry 

ceramic inlays in vitro   Clinical Oral Investigations  17(1) 177-183. 6. Ro Rogge ggend ndor orff MJ MJ,, Kr Kram amer er N, Di Dippo ppold ld C, Vo Vose sen n VE VE,, Naumann M, Jablonski-Momeni A, & Frankenberger R (2012) (20 12) Effe Effect ct of pro proxim ximal al box elevatio elevation n with resin composite on marginal quality of resin composite inlays in vitro   Journal of Dentistry  40(12)   1068-1073. 7. Diba Dibart rt S, Capri D, Kachouh I, Van Dyke T, & Nunn ME (2003) Crown lengthening in mandibular molars: A 5-year retrospective radiographic analysis  Journal of Periodontology  74(6)   815-821. 8. Gargiulo A, Wentz FM, & Orban B (1961) (1961) Dimensions and relations of the dentogingival junction in humans  Journal of Periodontology  32(3)  261-267. 9. Va Vace cek k JS JS,, Gh Gher er ME ME,, As Assa sad d DA DA,, Ri Rich char ards dson on AC AC,, & Giamba Gia mbarre rresi si LI (19 (1994 94)) The dim dimen ensio sions ns of the hum human an dentogingivall junction International Journal of Periodondentogingiva tics & Restora Restorative tive Dentistry  14(2)   154-165. 10. Ingb Ingber er JS JS,, Ros Rose e LF, & Cos Coslet let JG (19 (1977) 77) The ‘‘biol ‘‘biologi ogicc width’’— width ’’—A A conc concept ept in peri periodon odontics tics and rest restorati orative ve dentistry   Alpha Omegan  70(3)  62-65. 11. Nev Nevins ins M, & Sk Skuro urow w HM (19 (1984) 84) The int intrac racrev revicu icular lar restorati rest orative ve marg margin, in, the biologic biologic width width,, and the maintenance nanc e of the gingival margin   Internationa Internationall Journal of   Periodontics & Restorative Dentistry  4(3)   30-49. 12. Gunay H, See Seeger ger A, Tsch Tscherni ernitsche tschek k H, & Geurt Geurtsen sen W (2000) Placement of the preparation line and periodontal health—A prospective 2-year clinical study  International  Journal of Periodontics & Restorative Dentistry   20(2) 171-181. 13. Lanning Lanning SK, Waldrop TC, Gunsolley Gunsolley JC, & Mayn Maynard ard JG (2003) (200 3) Surg Surgical ical crown lengthening lengthening:: Evalu Evaluatio ation n of the biological width  Journal of Periodontology  74(4)   468-474. 14. Ne Newco wcomb mb GM (19 (1974) 74) The rel relati ation onshi ship p bet betwee ween n the location loca tion of sub subging gingival ival crow crown n marg margins ins and ging gingival ival   Journal of Periodontology  45(3) inflammation  151-154. 15. M Mayn aynard ard JG Jr, & Wi Wilso lson n RD (19 (1979) 79) Phy Physio siolo logic gic dimensions of the periodontium significant to the restorative dentist   Journal of Periodontology  50(4)   170-174. 16. Flores-de-Jacoby Flores-de-Jacoby L, Zafiropoulos GG, & Ciancio S (1989) Effect of crown margin location on plaque and periodontal International al Journal of Perio Periodontics dontics & Restor Restor-health   Internation ative Dentistry  9(3)   197-205. 17.. Opd 17 Opdam am NJ NJ,, Ro Roet eter erss JJ JJ,, de Bo Boer er T, Pe Pess ssch chie ierr D, & Bronkh Bro nkhors orstt E (20 (2003) 03) Voi Voids ds and por porosi ositie tiess in Cla Class ss I micropre micr opreparat parations ions fill filled ed with vari various ous resi resin n comp composite ositess Operative Dentistry  28(1)  9-14. 18. Hempton TJ, & Dominici Dominici JT (2010) Contemporary Contemporary crownlengthening therapy: A review   Journal of the American  Dental Association  141(6)   647-655.

4. Stefanski S, & van Dijken Dijken JW (2012) Clinical performance performance of a na nanof nofill illed ed res resin in com compos posite ite wit with h an and d wit withou houtt an interm int ermedi ediary ary lay layer er of flo flowab wable le com compos posite ite:: A 2-y 2-year ear evaluation  Clinical Oral Investigations  16(1)  147-153.

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5. Frankenberger Frankenberger R, Hehn J, Hajto J, Kramer N, Naumann M, Koch A, & Roggendorf MJ (2013) Effect of proximal box elevation with resin composite on marginal quality of 

20. Padbury Padbury A Jr, Eber R, & Wang HL (200 (2003) 3) Interaction Interactionss betwe be tween en the gin gingiv giva a and the mar margin gin of res restora toratio tions ns  Journal of Clinical Periodontology  30(5)   379-385.

 

Frese, Wolff & Staehle: Proximal Box Elevation and the Dogma of Biological Width 

21. Silne Silness ss J (198 (1980) 0) Fixe Fixed d prost prosthodo hodontics ntics and peri periodon odontal tal health  Dental Clinics of North America  24(2)   317-329. 22.. Brun 22 Brunsvo svold ld MA, & Lan Lane e JJ (19 (1990) 90) The pre preval valen ence ce of  overhanging dental restorations and their relationship to Journal of Clini Clinical cal Perio Periodontolo dontology gy periodontal disease   Journal 17(2)  67-72. 23. Wang HL, Burgett FG, & Shyr Y (1993) The relationship relationship between restoration and furcation involvement on molar teeth   Journal of Periodontology  64(4)  302-305.

 

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26. Francisconi LF, Scaffa Scaffa PM, de Barros VR, Coutinho M, & Francisconi PA (2009) Glass ionomer cements and their role rol e in the res restor torati ation on of no non-c n-cari arious ous cer cervic vical al le lesio sions ns  Journal of Applied Oral Science: Revista FOB   17(5) 364-369. 27. Lindberg Lindberg A, van Dijk Dijken en JW, & Lind Lindberg berg M (2007) Nineyear eval evaluatio uation n of a poly polyacidacid-modi modified fied resi resin n comp composite osite/  /  resin res in com compos posite ite ope open n san sandwi dwich ch tec techn hniqu ique e in Cla Class ss II

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25. Dietrich Dietrich T, Losche AC, Losche GM, & Roul Roulet et JF (199 (1999) 9) Marginal Margi nal adap adaptatio tation n of dire direct ct comp composite osite and sand sandwich wich restorations in Class II cavities with cervical margins in dentine Journal of Dentistry  27(2)  119-128.

29. Dietr Dietrich ich T, Kra Kraem emer er M, Los Losche che GM, We Werne rnecke cke KD, & Roulet Roul et JF (200 (2000) 0) Infl Influenc uence e of dent dentin in cond conditio itioning ning and contamina conta mination tion on the margi marginal nal inte integrity grity of sand sandwich wich Class II restorations   Operative Dentistry  25(5)  401-410.