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CLINICAL RESEARCH pyrig

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Adhesive Restorations in the te ot

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ss e n c e
fo r

Posterior Area with Subgingival


Cervical Margins: New Classification
and Differentiated Treatment
Approach
Marco Veneziani
Visiting professor, University of Pavia, Italy
Private practice, Vigolzone (Piacenza), Italy

Correspondence to: Dr Marco Veneziani


Via Roma 57 - 29020 Vigolzone (PC), Italy
phone/fax:+39 0523 870362; mobile: +393351435187; e-mail: marco.veneziani@nesh.biz

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Abstract te 2) a
isolation through the dental dam) and n
ot

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biological parameter (depending on the ss en e
fo r
c
The aim of this article is to analyze some of biologic width). Three different clinical situ-
the issues related to the adhesive restora- ations and three different therapeutic ap-
tion of teeth with deep cervical and/or sub- proaches are identified (1st, 2nd, and 3rd,
gingival margins in the posterior area. respectively): coronal relocation of the mar-
Three different problems tend to occur dur- gin, surgical exposure of the margin, and
ing restoration: loss of dental substance, clinical crown lengthening. The latter is as-
detection of subgingival cervical margins, sociated with three further operative se-
and dentin sealing of the cervical margins. quences: immediate, early, or delayed im-
These conditions, together with the pres- pression taking.
ence of medium/large-sized cavities asso- The different therapeutic options are de-
ciated with cuspal involvement and ab- scribed and illustrated by several clinical
sence of cervical enamel, are indications cases. The surgical-restorative approach,
for indirect adhesive restorations. Subgin- whereby surgery is strictly associated with
gival margins are associated with biologi- buildup, onlay preparation, and impression
cal and technical problems such as difficul- taking is particularly interesting. The restora-
ty in isolating the working field with a dental tion is cemented after only 1 week. This ap-
dam, adhesion procedures, impression proach makes it possible to speed up the
taking, and final positioning of the restora- therapy by eliminating the intermediate
tion itself. phases associated with positioning the pro-
A new classification is suggested based visional restorations, and with fast and effi-
on two clinical parameters: 1) a technical- cient healing of the soft marginal tissue.
operative parameter (possibility of correct (Eur J Esthet Dent 2010;5:5076)

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Introduction well-integrated conservative restoration
te ot n

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ss
fo r
en c
that can be retreated at a later date, either e
From the mid 90s onwards, materials and endodontically or for reconstruction.7
adhesive techniques have evolved consid- Therefore, as the therapeutic arsenal
erably and have led to changes in the for rehabilitation in the posterior areas has
restorative approach to the posterior area, changed, there is now an overall preva-
and in the treatment plan.1 The need to lence of adhesive restorations and their
carry out composite restorations in the pos- different application techniques (direct,
terior area is not only for esthetic reasons semi-direct, indirect). Silver amalgam is no
but primarily concerns the principle of bio- longer indicated, except in certain clinical
economics (maximum conservation of applications. Gold onlays maintain their
healthy tissue) and of reinforcing the effectiveness in cases of minimum inter-
residual dental structure.2 The most suit- occlusal spaces (gold being the only ma-
able materials for this type of restoration are terial with the physical-mechanical proper-
microhybrid or nanoparticle composites ties suitable for thicknesses less than
as, being densely filled, they have excellent 1 mm) or in parafunctional patients. The
physical-mechanical properties, are ra- number of single elements requiring pros-
diopaque, have an elasticity module simi- thetic restoration has been considerably
lar to dentin, and have a resistance to wear reduced and therefore the line between
that is comparable to enamel and amal- conservative treatment and replacement
gam (10.30 m/year). For these reasons, has changed. Finally, with regard to seri-
3
they are suitable for all types of cavities. If ously affected teeth, the development of
used correctly, the new materials and ad- implant techniques and evidence regard-
hesive techniques available today can ing osseointegration and guided bone re-
guarantee excellent, long-term results.4,5 generation (GBR) processes sometimes
There are, however, some problems makes implant-prosthesis treatment more
that have yet to be completely resolved predictable compared to restoration.
and these are linked to polymerization In the present study, the main objectives
contraction and dentinal adhesion, prima- of reconstructive treatment remain un-
rily in major reconstructions using a direct changed and they are the following:
technique. Such problems have led to the I restore correct biologic width in relation
development of semi-direct and indirect to the positioning of the restoration, con-
approaches in composite restorations servation, or prosthetic margins. It is im-
where everything is completely cured be- portant to underline that, in the case of
fore it is cemented into the cavity.6 adhesive restorations, cervical banding
An adhesive approach allows dental (a fundamental requirement for pros-
structures to be maintained even when not thetic restorations) is unnecessary. How-
completely supported by dentin and to ever, an adequate distance between
preserve the vitality of teeth in cases where the cervical cavity margin, correctly
traditional metallic techniques would re- cleansed of decay, and periodontal at-
quire root canal therapy in order to use the tachment must be restored. This in-
pulp chamber in a retentive capacity. The evitably leads to a more conservative
result is an esthetically and functionally type of resective surgical approach.

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I re-establish correct occlusal function, Significant loss te n ot

n
which means that restorations are able ss e n c e fo r
of dental substance
to provide stability to the occlusion itself
in the absence of pre-contacts and/or According to the classification compiled by
lateral and protrusive interference the school of Geneva in 1994,7 composite
I restore the morphological and, if possi- resins can be used in the posterior areas
ble, esthetic integrity of the tooth with different techniques: direct, semi-
I guarantee excellent coronal marginal direct, and indirect. The choice of technique
sealing, which is absolutely necessary is dictated by the following parameters:
for the lifespan of the restoration itself, I general; such as oral hygiene, suscepti-
but also for the conservation of an api- bility to decay, parafunctions, age, esthet-
cal seal. ic requirements, and economic means
I local; such as cavity shape and dimen-
sions, number of restorations, margin
Restoration problems positions, quantity of residual cervical
enamel, and position of tooth in the arch.
Second class restorations with deep cervi-
cal margins generally entail three different Direct techniques are indicated for Class I
problems in the restoration phase: and Class II preventive restorations of small
I substantial loss of dental substance or medium dimensions with the presence
I subgingival cervical margins of cervical enamel. It is evident that the
I partial or total sealing of the cervical above conditions are rarely found in carious
margins in the absence of enamel (with lesions which extend to the subgingival lev-
dentin and cementum). el. As a rule, the latter cases are associated
with cavities of wide dimensions, often with
In the above situations, there are two dif- the need for cuspal coverage with conse-
ferent clinical problems: biological (ie, the quent problems relating to contraction
relationship with marginal periodontal tis- stress. Polymerization contraction, in fact, is
sues), and technical-operative problems linked to the conversion of monomers to
such as difficulty in isolating the operative polymers in a network structure, with con-
field by means of the dental dam, adhe- sequent decrease in volume. The effects of
sion procedures, impression taking, and polymerization stress are evident at two lev-
successive phases of adhesive cement- els: a) in relation to the cavity, with possible
ing, finishing, and polishing. distortions or micro-fractures of the walls
These problems will be analyzed in or- themselves; and b) at marginal interface
der to formulate a clinical classification of adhesive level (with consequent micro-
the different situations and related differen- infiltration), or internal (with consequent
tiated therapeutic approaches. compression hypersensitivity).8 To counter-
act polymerization contraction and improve
marginal adaptation of Class II restorations,
various procedures have been suggested
(use of terminals for condensation-poly-
merization,9 positioning of glass or ceramic

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inserts,10 use of bases in glass ionomer ce- 16
te 12 to on
equal to 13.2 m/year; average wear ot

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ment), while polymerization segmentation11 17
15 m/year; wear supersedes enamelss e n c e
fo r
by means of multi-layered techniques and amalgam;18,19 a 17-year study showed
(horizontal, oblique, four increments) is average wear of 15.5 m/year.20 Finally,
particularly efficient. However, these tech- Ferracane et al in 1996 stressed how the
niques are not considered efficient enough degree of wear is linked to the volume per-
for application in cavities of large dimen- centage of the filler, the resin-filler bonding,
sions with possible cusp coverage, where and the conversion level of the polymer.21
a major compensation for immediate poly- In any case, a bibliographical search in
merization stress is necessary, unlike spon- PubMed from 1970 to 2004 shows that
taneous post-polymerization which contin- 6,521 articles have been published on the
ues for several days after insertion of the problem of wear, a sign that the problem is
composite.12 In these conditions (cavities of not easily interpreted.
large dimensions, cusp tip, reduced thick- Similarly, published data concerning
ness of cervical enamel), adhesively ce- composite restoration longevity are also
mented restorations are indicated using encouraging: Skeeters et al,22 after 15
7
semi-direct or indirect techniques. The fun- years, 95% of adhesive restorations main-
damental advantage of these cemented tained their function; Kohler et al,23 the 5-
techniques is the possibility of reducing the year duration was due to correct selection
polymerization contraction of the material, of cases and cario-receptiveness; Wassel
which occurs outside the cavity, to a max- et al,24 after 5 years, 17% of failures were
imum with consequent benefits for mar- inlay restorations and 8% were direct com-
ginal adaptation. The only residual poly- posite ones; and Van Dijken,25 after 11
merization contraction, which is not very years, composite onlays using intraoral
significant, relates to the thin layer of resin techniques survived in 83% of cases. Sim-
13
used for cementing. Moreover, post-poly- ilar data can also be seen in the 11-year
merization with photothermic treatment of random longitudinal clinical study by
the manufactured part improves the degree Pallesen and Qvist:26 direct composites
of conversion and, as a consequence, the presented a failure rate of 16% and inlay
physical-mechanical properties of the restorations 17%, with an annual failure
restoration (wear resistance14 and dimen- rate of 1.5%. An important review of the
15
sional stability ). Other advantages of such clinical longevity of direct and indirect
methods include the possibility of ideal restorations in the posterior area after 15
anatomic modeling and occlusal rehabilita- years was published by Manhart et al,4
tions verified with an articulator. which reported the following data on the
It is obviously important to evaluate wear average annual failure rate: 3% amalgam,
resistance and average duration of restora- 2.2% direct composites, 2.9% composite
tions in order to decide which technique to onlays, 1.9% ceramic restorations, 1.7%
use for wide restoration of dental elements CAD-CAM ceramic restorations, and 1.4%
with the covering of one or more canines. gold onlays. Finally, Opdam et al5 pub-
An analysis of international publications lished a retrospective clinical study on
shows encouraging data regarding com- 1,955 composite restorations of dental el-
posite material wear: after five years wear ements in the posterior area, with a

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longevity rate of 91.7% after 5 years and eral of these requirements. It is important
te ot n

n
82.2% after 10 years. s
to preserve as much residual healthy tis-s
fo r
en c e
Published data aside, it can be af- sue as possible and obtain a thin smooth
firmed with reasonable certainty that the layer of adhesive cement by means of a
predictability of success and therefore the buildup in order to control contraction
longevity of restorations are closely con- stress during cementing.
nected with accuracy in the implementa- In cases with slightly subgingival mar-
tion of procedures as well as compliance gins, it is possible to relocate the cervical
with protocols and indications. The im- preparation to above gingival levels by
portance of the operator factor has applying an appropriate increment of
been previously reported. composite resin over the pre-existing
margin. This is known as coronal margin
relocation and was first proposed in 1998
Partial or total cervical by Dietschi and Spreafico29 to simplify the
clinical procedures of adhesive cementa-
margin sealings in the
tion. The technique representsin some
absence of enamel
specific casesa non-invasive alternative
(in dentin and cementum) to surgical crown lengthening.
Frequently, cavities of large dimensions ex- The operating procedure was then de-
tend beyond the cementoenamel junction fined by means of an in vitro study by Ols-
with margins more or less deeply located burgh30 and establishes the following: rig-
in the gingival tissue and with little or no orous isolation of the field with a dental
residual enamel. While adhesion to mordant- dam, positioning of a matrix to guarantee a
treated enamel is predictable and safe, cervical seal, thorough cleansing of the
adhesion to dentin and cementum is de- cavity finishing with a bicarbonate spray,
pendent on numerous and complex phe- adhesive phase with a three-step etch-
nomena. The formation of an efficient hy- and-rinse method, and raising of the cervi-
brid layer is influenced by many clinical cal step with flowable composite of maxi-
steps (etching, drying, primer application, mum 1 mm thickness. Following this
bonding application), including the poly- protocol, 98% of margins obtained by the
merization of adhesive resin that stabilizes author were excellent.
the structure of the hybrid layer itself. How- As mentioned above, the technique re-
ever, a problem with the lasting stability of quires the use of flowables. Flowables are
the adhesion exists.27,28 composites of low-viscosity, due to the re-
As already highlighted, indirect adhe- duced volume of inorganic filling particles
sively cemented restorations are suitable (44 to 55%). As they contain a higher quan-
in the above conditions. These require a tity of resinous components, they present
cavity of adequate configuration and higher volumetric contraction but lower
shape with smooth and well-defined diver- stress contraction: they have a low Youngs
gent walls, clean rounded internal angles, module (3.6 to 6.7 GPa) and therefore a
bevel-free butt enamel finishing, and a lo- higher level of elastic deformation and in-
7
cation above gingival margins. The appli- trinsic internal flow capacity. The impor-
cation of a base is necessary to satisfy sev- tance of incorporating an elastic layer in the

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buildup has been emphasized by various I te that on
immediate dentin sealing: it seems ot

n
authors, including Kemp-Scholte and dentin adhesive improves bonding ss e n c e
fo r
Davidson,31 in order to make up for the strength if it is applied to dentin pre-
contraction stress and act as a stress ab- pared immediately beforehand44
sorber. It is now a common procedure, I protection of the adhesive film: all sim-
both in direct and indirect restorations. plified adhesives, and to a lesser extent
However, the use of the flowable as a even the etch-and-rinse adhesives, act
first increment for the cervical step is con- as semi-permeable membranes allow-
troversial; several authors32-35 maintain that ing oozing of dentinal fluid and conse-
there is no significant trend in the reduction quent loss of complete adhesive effi-
of micro-leakage in Class II restorations ciency45
when a thin layer of flowable composite is I composite-composite adhesion is pos-
applied under restoration composite. A sible and efficient if carried out within 30
31,36-42
higher number of authors maintain days,46,47 but in the specific case of on-
that when flowable is applied as the first lays, the final cementing is carried out in
cervical increment in Class II restorations, 7 to 10 days.
gingival micro-leakage is reduced and
marginal integrity is improved. In particu- It is clear that all adhesive procedures
lar, in an article by Dietschi et al,39 the au- must be strictly carried out in an isolated
thors clearly suggest that the use of a field. The isolation of the field by means of
medium-rigid flowable composite (7.6 a dental dam protects the restoration from
GPa) is a potentially valid material to dis- contamination by saliva, blood, gingival
place, in a coronal position, proximal mar- crevicular fluid, breath moisture and in-
gins under composite inlays. creases the comfort of both patient and
In the absence of reliable scientific evi- operator. Moreover, it has been reported
dence, but on the basis of published data that dental surfaces are contaminated by
and clinical experience, the importance a salivary organic film which creates a
and the systematic use of flowable com- very low surface tension (28 dynes/cm2)
positeat the cervical level in the absence and prevents adequate wetting of the ad-
of enamelcan be supported according to hesive with consequent absence of
the following rationale: bonding.48 Therefore, the use of a dam is
I interposition of an elastic layer of con- an unavoidable and integral phase of
trolled thickness (0.5 to 1 mm) between treatment.
the dental substratum and restoration
material. This allows contraction stress
to be absorbed and the adhesive inter- Subgingival cervical
face to be preserved.8,31,38,43
margins
I fluid adaptation to the cavity floor with
absence of blisters and visual control of The final restoration issues concern the re-
the cervical seal prior to correct posi- lationship with soft tissue and therefore the
tioning of matrix and wedge frequent presence of subgingival margins.
I straightening of the cervical margin as A retrospective clinical analysis on ad-
a result of burring hesively cemented restorations carried out

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by the author during an observation peri- I
ess c e n
restoration of a correct biologic t width, ot

n
fo r
od from 2000 to 2006, has brought to light wherever this has changed due to the en
much data, as yet unconfirmed by other processes of decay, coronal fractures,
scientific studies, but interesting from a or pre-existing inadequate restoration
clinical point of view. margins in subgingival positions, to
A total of 524 onlays were carried out, of make the margins easily accessible for
which 124 were on premolars (23.7%) and conservative treatment or impression
400 on molars (76.3%). An inlay restoration taking in the case of indirect restorations
was used in 65 elements (12.4%), onlay in I accuracy in carrying out restorations in
269 elements (51.5%), and overlay in 190 the preparation, finishing, and polishing
elements (36.2%). stages
In total, 335 (64%) of the treated ele- I adequate hygienic aftercare both at
ments were live tissue and 40 (12%) un- home and in the dental clinic.
derwent surgical lengthening of the clinical
crown. A total of 189 (36%) teeth were From the historical studies of Gargiulo et
treated endodontically (devitalization and al,49 the average values of dentogingival
root canal treatment). Of the endodontical- junctions are known: sulcus 0.69 mm,
ly treated teeth, 61 (32.2%) underwent junctional epithelium 0.97 mm, connective
lengthening of the clinical crown. attachment 1.07 mm with a total biological
In conclusion, the highest percentage of dimension (epithelial + connective attach-
onlay restorations was carried out on mo- ment) of 2.04 mm. It must be stressed that
lars. Of these, 88% of cases were restora- the above-mentioned values are average
tions of large dimensions with partial or to- ones and can vary greatly, especially the
tal cusp coverage. Despite this, in a high epithelial attachment.
percentage of cases (64%), it was possible Studies on animals and clinical and his-
to maintain the vitality of the elements in tological observations of human teeth50,51
keeping with modern principles of the bio- have widely demonstrated that periodon-
economy of hard tissues and pulp. Finally, tal health is jeopardized by gingivitis and
it is interesting to note that in nearly 12% of loss of attachment associated with sub-
live teeth and in more than 32% of teeth marginal restorations. Flores-de-Jacoby et
treated endodontically, a lengthening of al52 has demonstrated in humans that the
the clinical crown was necessary to ex- presence of subgingival margins can lead
pose deep cervical margins in subgingival to an increase in bacterial plaque, gingival
positions. indices, and probing depth with immediate
It is clear that the topic of discussion development of more aggressive bacteri-
gains particular importance from a clinical al morphotypes.
point of view. A treatment strategy with Therefore, in the presence of subgingi-
restorations that are correctly integrated val cervical margins due to deep carious
with the marginal periodontal tissues re- lesions, coronal fractures or prosthetic re-
quires adherence to the following univer- operations, it is absolutely necessary to re-
sally recognized principles: establish an adequate biologic width by
I restoration of periodontal health by surgically lengthening the clinical crown.
means of correct initial preparation Surgical lengthening of the clinical crown

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can be carried out in three ways:53 a) gin- teelement on
Finally, an important and significant ot

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ss e nc e
fo r
givectomy (resetting of the margin without is the post-surgical timing of wound heal-
resetting the clinical attachment), b) apical ing, depending on the successive restora-
positional flap (APF) (resetting of the mar- tive phases.58 Wound healing in the tooth-
gin and resetting of the clinical attachment), tissue interface progresses according to a
and c) APF with bone resection (resetting predictable sequence.59,60 The epithelium
of the margin with removal of supporting cells at the wound margin start to migrate
bone). within 12 hours and progress by 0.5 to
It is clear that the gingivectomy and APF 1 mm/day, and within 2 weeks a new junc-
without bone reduction are limited tech- tional epithelium is formed, even though it
niques as bone removal is very often nec- is not strong enough to withstand restora-
essary to create an adequate distance be- tive operations that involve the gingival mar-
tween the bone crest and the planned gin. The formation and maturation of the un-
restoration margin, depending on the bio- derlying connective attachment require
logic width. The method most commonly more time. Within a week the space previ-
used therefore, is the creation of a vestibu- ously occupied by the blood clot is substi-
lar flap of double mixed thickness and a tuted by immature granulation tissues, and
palatine flap of total thickness with ade- at 2 weeks immature connective tissue is
quate resecting bone surgery and apical formed which is low in collagen. At 8 weeks,
positioning on or slightly above the crest of the surgical site has a mature junctional ep-
tissues with vertical mattress sutures to the ithelium and a connective attachment
periosteum. Numerous authors have sug- which are incorporated in the new cement.
gested surgical removal of periodontal Therefore, the tissue should be adequate to
support so as to create a distance be- sustain the trauma connected with restora-
tween the planned restorative margin and tion procedures involving the gingival mar-
the level of the newly modeled bone crest gin. From 8 weeks to 6 months, the connec-
equal to 3 mm54 or 2.5 to 3.5 mm55 of ex- tive attachment matures with a change in
posed tooth. These exposed dental struc- the predisposition of the collagen fibers
ture figures are considered suitable to re- from parallel to perpendicular to the radic-
ceive a new gingival unit formed by the ular surface. In esthetic areas with prosthet-
regrowth of supercrestal soft tissue that ic restorations, it is advisable to wait 5 to 6
will proliferate coronally during healing, months after surgery so as to have attained
and to leave a sufficient quantity of dental margin tissue stability.
tissue to complete the restorative proce-
dures.56,57 The most commonly accepted
minimum distance between the bone New classification
crest and final restorative margin is 3 mm
of adhesive restorations
and assumes an average of 1 mm of su-
with subgingival cervical
percrestal connective attachment, 1 mm
of junctional epithelium, and 1 mm of sul-
margins
cus depth, even though considerable indi- The classification is based on clinical evi-
vidual variations should be taken into ac- dence. Isolation of the field with dental dam
count. and compliance with the biologic width

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when carrying out adhesive restorations Differentiated therapeutic
te n ot

n
are clinically evident and widely described ss e n c e fo r
approach
in the literature, facts that have been fully
discussed. A differentiated therapeutic approach cor-
The proposed classification is therefore responds to the three different clinical sit-
based on two decision-making parame- uations above:
ters in clinical order: I Grade 1: coronal relocation of the mar-
1) technical-operating parameter: possi- gin using flowable composite with a
bility of a correct isolation of the field maximum thickness of 1 to 1.5 mm, fol-
with rubber dental dam lowed by buildup, preparation, and im-
2) biological parameter: measuring the pression. Adhesive cementing of the
distance between the cleansed cervical onlay after 7 days.
margin and periodontal attachment, or I Grade 2: surgical exposition of the mar-
the bone crest, with a periodontal probe gin using flowable composite of 0.5 mm
and radiography. thickness at the cervical margin level fol-
lowed by buildup, preparation, and im-
Using the above parameters, three differ- mediate impression. Adhesive cement-
ent clinical situations can be identified and ing of onlay 7 days after removal of the
defined according to their importance in sutures.
three grades: I Grade 3: surgical lengthening of the
I Grade 1: the rubber dam, correctly clinical crown using three different op-
sheathed in the sulcus, is sufficient to erative sequences depending on differ-
show cervical margin with an adequate- ent clinical situations: a) immediate im-
ly prepared cavity. pression, b) early impression, and c)
I Grade 2: the rubber dam does not allow delayed impression.
a correct isolation of the field but the bi- - 3a) surgical crown lengthening, posi-
ologic width is respected (distance be- tioning of the rubber dam, flowable
tween margin and connective tissue at- composite at cervical level of 0.5 mm
tachment > 2 mm, or between margin controlled thickness followed by
and bone crest > 3 mm). This situation buildup, preparation, and immediate
is made possible by the fact that in the post-surgical impression. Adhesive
posterior areas, particularly in patients cementing after 7 days, immediately
with a thick periodontal biotype, the gin- after removal of sutures. Approach
gival sulcus sometimes presents a generally adopted in cases of single
probe depth of at least 3 mm.61 vital teeth or those already treated en-
I Grade 3: the cavity cervical margin (fol- dodontically.
lowing carious lesions or coronal frac- - 3b) surgical crown lengthening and
ture) is subgingival with violation of the pre-endodontic reconstruction in first
biologic width (distance between mar- appointment, canal therapy in a sec-
gin and connective tissue attachment ond appointment, and then early im-
< 2 mm, or between margin and bone pression taking at 3 weeks (time
crest < 3 mm). needed for re-epithelisation of tis-
sues56), subject to positioning of dam,

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flowable composite at cervical level of Case 1 - Grade 1) Coronalt
ess c e n
ot

n
fo r
0.5 mm controlled thickness followed margin relocation en
by buildup and preparation for onlay. A 36-year-old patient (teeth 45, 46, and 47)
Adhesive cementing after 7 days. Ap- presented inappropriate gold restorations
proach generally adopted in cases of with traces of further inadequate work
single elements where necessary en- (Fig 1a). After removal of the restorations
dodontic treatment has not yet been and careful removal of the decayed tissues,
carried out. cavities of very large dimensions with un-
- 3c) surgical crown lengthening, tem- supported walls remained (Fig 1b). With a
porary reconstructions (pre-endon- modern adhesive approach, it was possible
dontic) in glass ionomer cement with to rehabilitate these elements without re-
impression delayed for 8 to 12 weeks sorting to prosthetic treatment, while main-
(time needed for maturation of the tis- taining their vitality. It was evident that indi-
sues), subject to positioning of the rect cusp coverage restorations were
dam, flowable composite at cervical required. In spite of the high level of destruc-
level of 0.5 mm controlled thickness tion and the partial or total lack of interprox-
followed by buildup and preparation imal cervical enamel, the correctly sheathed
for onlay. Adhesive cementing after 7 dam made it possible to evidence the mar-
to 10 days. Approach generally adopt- gins and position matrices which suitably
ed in cases of multiple restorations, adhered to the cervical profile. This also
quadrant rehabilitations, or complex made it possible to carry out the adhesive
cases with possible prosthetic treat- phases and the subsequent reconstructive
ment of several elements. clinical phases in complete safety.
Under these conditions, a coronal relo-
It is important to emphasize thatirrespec- cation of the margins was carried out, us-
tive of the operation sequence used ing flowable composite 1 to 1.5 mm thick
when the tissues have matured and at cervical level and 0.5 mm thick to com-
healed, the boundary between tooth and pletely line the remaining part of the denti-
restoration at the cervical level may be nal cavity (Fig 1c). The buildup was then
slightly inter-sulcular, but it must be reach- completed in composite and preparations
able and easy to clean with dental floss in were made for overlay (teeth 46 and 47)
daily oral hygiene routines at home. and onlay (tooth 45) (Fig 1d). A precision
impression was taken and the laboratory
supplied the parts to be cemented (Fig 1e),
Clinical cases of the which needed to be carried out, if possible,
after 7 days. The onlays were tried before
proposed classification
isolation of the field and adhesive cement-
Adequate clinical documentation is sup- ing was conducted using the dam (Fig 1f).
plied to support what has been said in re- The final result shows correct integration of
lation to the proposed classification, with a restorations after finishing and polishing
close examination of the clinical aspects from a morpho-functional and esthetic
and the operational sequences peculiar to point of view, as well as a good response
each therapeutic approach. from marginal tissues (Fig 1g).

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a b

c d

e f

Fig 1 Quadrant 4: (a) inadequate gold restorations


with evidence of recurrent decay and inadequate com-
posite patch work, (b) teeth 45, 46, and 47 with cleansed
cavities of ample dimensions with unsupported walls
and deep cervical margins with enamel reduced or ab-
sent at the interproximal level (the dental dam allows
correct isolation of the field), (c) positioning of the ma-
trices and coronal relocation of margins with flowable
composite of thickness 1 to 1.5 mm, (d) preparations for
onlay of tooth 45, and overlay of teeth 46 and 47, sub-
ject to layered buildup, (e) composite onlays carried out
with indirect technique, (f) adhesively cemented
g
restorations, and (g) final rehabilitation with suitable
morphofunctional and esthetic integration, and good
marginal tissue response.

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Case 2 - Grade 2) Surgical te crest on
attachment by planing up to the ot

n
exposition of the margin and ss e n c e
from the exposed root and consequent
fo r
immediate impression removal of the cement, a spontaneous re-
A young patient presented unsuitable modeling of the bone crest was unavoid-
restorations (teeth 37, 36, and 35) (Fig 2). able, and is described in dental publica-
The field had to be isolated and the fillings tions as varying between 0.2 to 1 mm,
and decayed tissue of the two molars were average 0.5 to 0.6. The flaps were repo-
removed. Large cavities were left with par- sitioned in the crest with a simple inter-
tially sustained walls. The cervical margins rupted suture and thus, when the dental
presented an adequate quantity of enam- dam was repositioned, the dentin was
el above the gingival margin on the mesial lined with flowable composite. After
surface of teeth 46 and 47, while the distal buildup, preparations for onlay were de-
margin of tooth 46 presented reduced or fined (Fig 5). At this point, an immediate
absent enamel, partially subgingival, and a post-surgical impression was made
correct isolation of the field was problem- (Fig 6). The correct impression outline was
atic (Fig 3). The dam was therefore re- made possible by vasoconstriction in-
moved and by means of a periodontal duced by the anesthetic, by precision in
probe, a margin to connective tissue at- sculpting the tissue in order to reduce
tachment distance of > 2 mm could be bleeding and by the correct supragingival
seen. Therefore a surgical exposition of position of the now exposed margins. Af-
the margin was conducted by means of a ter 7 days, immediately after the removal
chamfered flap with removal of a wedge of of the sutures, the adhesive cementing of
soft inter-dental tissue to allow for a correct indirect composite restorations (Figs 7
operating procedure in the successive and 8) was completed. It can be seen that
clinical phases (Fig 4). besides a good aesthetic and morpholog-
It is particularly important to stress how ical integration, a rapid and favorable
in this phase, without the use of burrs, lib- healing and maturation of the tissues was
erating the supercrestal connective tissue evident after 4 months (Fig 9).

Fig 2 Quadrant 3, initially with a need for re-treatment Fig 3 Molar cavities after removal of restorations and
of teeth 35, 36, and 37. cleansing of lesions. The distal margin of tooth 46 is in
a partial subgingival position, creating problems for
correctly isolating the field.

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Fig 4 Surgical exposition of the distal Fig 5 Positioning of the post-surgical dam, buildup,
margin of tooth 46 by means of internal and definition of preparations for onlays.
chamfered flap and removal of a wedge of
soft tissue.

Fig 6 Immediate post-surgical impression. Fig 7 Composite onlays carried out in the laboratory.

Fig 8 Adhesive cementing of restorations. Fig 9 Control after 4 months with evident toothtissue
integration.

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Case 3a - Grade 3a) Surgical tea good on
mesial cervical margin presented ot

n
nc e
ss efree
fo r
crown lengthening with immedi- quantity of enamel, which was left
ate post-surgical impression and clean.
Tooth 26 presented inappropriate amal- Once the layered buildup in composite
gam restorations with evident marginal had been carried out, the final preparation
carious infiltrations, due also to a fracture for onlay was defined (Fig 15). When the
of the filling at the distal level (Fig 10). The dam was removed, making the most of the
bitewing radiograph clearly revealed the vasoconstriction induced by the anesthet-
presence of carious recurrence. The dam- ic, a precision silicone, postoperative im-
age was very near the pulp and deeply in- pression was taken immediately with a
volved the distal cervical step (Fig 11). Check-Bite tray according to a monophase
Once the dam was positioned, the old fill- dual-arch method.62
ing was removed and after an initial After a week, the sutures were removed
cleansing of the decayed tissue, the den- and the onlay in composite was tried us-
tal dam no longer sealed at the cervical ing the indirect method (Fig 16). The onlay
step level (Fig 12). This clinical sign, to- was then cemented according to a strict
gether with the periodontal probe and protocol.
radiographic examinations indicated a The final restoration showed suitable
restoration procedure only after the recov- marginal adaptation and good morpho-
ery of the biologic width of the tooth. The logical, functional, and esthetic integra-
clinical crown was surgically lengthened tion. Moreover, the positive response of
by means of a mixed double V flap and re- the soft marginal tissues is evident, as
duced P. An ostectomy and osteoplasty they show signs of rapid healing only 20
were performed with a palatine ramp, days after surgery: this is one of the most
recreating a positive scalloped edging of interesting aspects of the method pro-
the bone crest (Fig 13). posed (Fig 17).
Once a width of nearly 3 mm from the A radiographic check at the end of the
distal conservative margin had been re- procedure is very important to check for
stored and carefully cleansed of decay, a any residual excess of composite cement
vertical mattress suture was carried out on (Fig 18).
the bone crest and anchored to the perios-
teum with crestal positioning of the flaps Case 3b - Grade 3b) Surgical
(Fig 14). Immediate post-surgical position- crown lengthening with early
ing of the dental dam was conducted, impression at 3 weeks
which now allowed correct isolation. The An 18-year-old patient presented a serious
cavity was prepared, with evaluation of the and destructive symptomatic carious le-
residual thicknesses and consequent re- sion on tooth 16. It could be seen clinical-
moval of unsupported tissue. Matrix and ly and radiographically that the pulp was
wedges, to guarantee correct marginal involved and there was a subgingival po-
sealing, were positioned. The next step sition of the distal surface of the tooth with
was the adhesive phase and the dentin violation of the biologic width (Figs 19 and
was completely coated with a 0.5 mm, thin, 20). As a result, endodontic treatment and
even layer of flowable composite. The periodontal surgery were necessary.

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Fig 10 Amalgam restorations of a maxillary molar Fig 11 Bitewing radiograph shows the presence of
with signs of carious infiltrations and fracture of the dis- a lesion near the pulp which deeply involves the distal
tal box. cervical step.

Fig 12 The dental dam, after removal of fillings and Fig 13 Lengthening of the clinical crown with bone
cleansing of caries, clearly does not allow an adequate resection (removal of supporting bone).
isolation of the distal cervical step.

Fig 14 Crestal positioning of flaps with sutures an- Fig 15 Immediate post-surgical positioning of the
chored to the periosteum. dental dam, removal of unsupported tissue, buildup,
and definition of the cavity shape and design for onlay.

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te a den- on
Being unable to isolate the field with ot

n
ss e n c e
fo r
tal dam, the first phase of the treatment
plan required a resective surgical ap-
proach (Fig 21) to re-establish a distance of
at least 3 mm between the cervical margin,
which had been carefully cleaned of the
carious lesion in the preoperative phase,
and the bone crest.
After the flaps had been sutured with
vertical mattress sutures (Fig 22), the post-
operative positioning of the rubber dam,
Fig 16 Trying out the onlay after one week, contex- the pulpotomy to avoid painful symptoms,
tually, with the removal of the sutures and successive and the pre-endodontic reconstruction in
adhesive cementing.
glass ionomer cement, the patient could
be discharged with a provisional restora-
tion, correct sealing, and contact point. In
the next appointment, which should prefer-
ably be 7 to 14 days later, root canal treat-
ment was carried out in an isolated field
with references for endodontic stops.
Three weeks after the surgical lengthen-
ingthe time necessary for canal treatment
to prevent bacterial colonization of the en-
dodontic space and allow for re-epithelial-
ization of the periodontal tissuesthe adhe-
sive buildup was performed in composite
Fig 17 The recall 3 weeks after the operation shows under rubber dam, by removing the provi-
a rapid and favorable healing of the tissues. sional reconstruction and applying a layer
of flowable composite at a controlled thick-
ness of 0.5 mm (Figs 23 and 24). Prepara-
tion was made for a total cusp coverage
onlay (Fig 25) and a precision impression
was taken. The onlay was manufactured in
the laboratory and was adhesively cement-
ed a week later (Figs 26 and 27).
A restoration of correct morphology,
emergence profile, interproximal contact
points, and well-finished and well-polished
margins with an absence of solutions of
continuity to control plaque is essential for
the longevity of the restoration and for the
Fig 18 Final radiograph shows marginal adaptation
correct maturation of the periodontal mar-
and re-establishment of an adequate biologic width.
ginal tissues.

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Fig 19 Serious and destructive symptomatic carious Fig 20 Apical radiograph shows the in-
lesions of the 1st maxillary molar. volvement of pulp and violation of the bio-
logic width.

Fig 21 Bone resection as first treatment phase. Fig 22 Crestal positioning of flaps and mattress su-
tures.

Fig 23 Cavities after removal of decayed tissue and Fig 24 Application of a flowable composite layer in
endodontic treatment, 3 weeks after the surgical length- a controlled thickness of 0.5 mm.
ening.

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Case 3c - Grade 3c) Surgical
te n ot

n
ss
crown lengthening with delayed en c e fo r
impression at 8 to 12 weeks
In cases of complex conservative rehabil-
itations when it is necessary to intervene
on one or more quadrants contemporar-
ily, a different approach from the ones
above is required. Complex rehabilita-
tions, in fact, require an approach which
allows the completion of, on more than
one tooth, all the provisional reconstruc-
Fig 25 Preparation for total cusp coverage onlay. tive phases, endodontic treatments, and
periodontal surgical treatments neces-
sary in one reconstructive phase, includ-
ing conservative restorations and, if nec-
essary, prosthetic restorations. The latter,
as described in the literature, require
more time (at least 2 to 3 months) for mat-
uration of the tissues and stabilization of
the gingival margins in the posterior ar-
eas.
To illustrate this, a case of a 32-year-old
patient needing extended rehabilitation of
the four quadrants as can be seen from the
right and left bitewing radiographs (Figs 28
and 29) is presented. The rehabilitative
Fig 26 Composite overlay manufactured in the lab-
phases of the right quadrantsin particu-
oratory. lar quadrants 1 and 4will be described.
Regarding the first quadrant (Fig 30),
once the endodontic emergency relating
to the symptomatic tooth 15 had been re-
solved and followed by the initial prepara-
tory stage, the first step was bone resec-
tion relating to teeth 15 to 17 in order to
re-establish correct biologic width prior to
removal of the old restorations, and care-
ful removal of decayed tissues (Fig 31).
Once the sutures had been applied, the
field was isolated with a dental dam and a
pulpotomy (tooth 17) and provisional re-
constructions of the two teeth in glass
Fig 27 Final adhesively cemented restoration. ionomer cement were carried out to create
a seal and a correct interproximal contact

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Figs 28 and 29 Initial bitewing radiograph right and left in patient with extensive caries.

Fig 30 Initial situation in quadrant 1 with serious decay at teeth 15, 16, and 17.

point. In the following appointment, en- successive preparations for onlays with
dodontic treatment of tooth 17 was com- configurations and shapes that took into
pleted. account the arrangement of the remaining
Three months after surgery, contem- healthy tissues (Fig 33).
porarily with the rehabilitation of quadrant The ideal appearance of the mature
4, the provisional restorations were re- marginal tissues (Fig 34) and the ease with
moved and the cavities re-cleansed which it was possible to take a precision
(Fig 32). A buildup was then begun with impression are evident. Once the models

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Fig 31 Bone resection contextual with the removal of Fig 32 Re-preparation of the cavity after 3 months
pre-existing restorations and cleansing of the carious and evaluation of residual dental thickness.
lesions with pulp exposure at tooth 17.

Fig 33 Buildup and definition of preparations for Fig 34 Appearance of marginal periodontal tissues
cusp coverage onlays. which have reached maturation.

Fig 35 Composite overlays and onlay. Fig 36 Quadrant 1 completed after adhesive ce-
mentation of restorations, finishing, and polishing.

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had been created, onlays were then car- The overlay for tooth 46 was built and
te ce- n ot

n
ried out using an indirect technique and mented at the same time as the onlays ess ofn c e
fo r
were adhesively cemented in a single ses- the first quadrant and with provisional
sion 10 days later (Figs 35 and 36). composite on tooth 47 (Figs 41 and 42).
With the fourth quadrant (Fig 37) being The latter would, in fact, be permanently re-
simultaneously treated, it was possible to placed with a ceramic crown coping in zir-
carry out the pre-endodontic reconstruc- conium at the same time as the prosthetic
tions first, then the canal treatment of teeth restoration of teeth in the third quadrant
46 and 47, and the direct restorations of tooth 36 on implant support and tooth 35
teeth 44 and 45. After that, bone resection on natural crown-radicular support (Figs 43
was performed on the molars with a double- to 46).
mixed vestibular flap and total lingual The final, satisfactory result of the com-
thickness (Fig 38). plete rehabilitation of the upper and low-
At this point, teeth 46 and 47, which were er arches can be clearly seen from the
rubber dam isolated with provisional bitewing radiographs and clinical photos
restorative materials and carious residues (Figs 47 to 51)
removed, were evaluated separately for The classic approach described for this
the preferred type of reconstruction. Tooth case is much more elegant than the
46 required buildup and preparation for combined surgical restorative approach
adhesive overlay, and 47 required a pre- with immediate impression or impression
prosthetic reconstruction in reinforced after 3 weeks. However, in the authors
composite with fiber post and preparation opinion, it should be reserved only for ex-
for a total crown. This was due to the wide- tended and complex cases since, for the
spread loss of tissue and absence of reasons outlined here, preference should
enamel at the cervical level, which involved be given to immediate or early finalization
the box area and, in part, the axial walls of all cases.
(Figs 39 and 40).

Fig 37 Quadrant 4: inadequate pre-existing restora-


tions with serious recurrent carious lesions.

Fig 38 Surgical crown lengthening of teeth 46 and


47 following canal treatments.

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Fig 39 Residual dental tissue after cleansing and Fig 40 Preparation for overlay on tooth 46 and total
endodontic therapies. crown on tooth 47.

Fig 41 Contextual construction of manufactured Fig 42 Definite restoration in adhesively cemented


parts in the two opposing quadrants. composite of tooth 46 and provisional restoration in
composite of tooth 47.

Fig 43 Final prosthetic preparation of tooth 47. Fig 44 Zirconium ceramic crown permanently ce-
mented

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Fig 45 Prosthetic preparation of tooth 35 Fig 46 Zirconium ceramic crown cemented


and implant fixture to replace tooth 36 that was on natural abutment of tooth 35 and ceramo-
previously extracted. metallic crown cemented on titanium abutment
screwed to the implant support of tooth 36.

Figs 47 and 48 Final right and left bitewing radiographs.

Fig 49 Recall 1 year after completed rehabil- Fig 50 Recall 1 year after completed rehabil-
itation of the maxillary arch. itation of the mandibular arch.

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approach allows the case to be tconclud- ot

n
fo r
en
ed in a very short time, eliminates prob-
lems connected with long intermediate
phases with provisional restorations, and
seals the cavity with a well-finished and
polished definitive restoration with suitable
emergence profiles, which allows for a rap-
id and favorable healing of the soft margin-
al tissues.
Fig 51 Intercuspation of the two left quadrants after
completed rehabilitation with good tissue response.

Acknowledgements
The authors would like to thank Pozzi Franco & C
S.N.C. (PR) Dental Technician Laboratories (Parma,
Italy) for implementing cases 1, 2, 3a and 3c, and Fio-
ra Moreno (Desenzano, Italy ) for case 3b.
Conclusion
The purpose of the present article is to
give the clinician a systematic, orderly, References
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