DEEP MARGIN ELEVATION

VS CROWN LENGTHENING

FATMA HAMED TOUNY

ASSOCIATE PROFESSOR OF ORAL MEDICINE AND
PERIODONTOLOGY
 OUTLINE
• Introduction to the concept of CMR
• Biological background
• Evidence-based sequalae of biologic width
violation
• Biologically-driven crown-lengthening
approach
• Crown-lengthening vs DME/CML
• Decision-making process
INTRODUCTI
ON
INTRODUCTION

One of the difficulties of a

conservative approach is
Over the past decade, most determining its limits and
dental procedures have knowing situations that
moved towards a more require changing the shape
conservative approach. of tissues around teeth to
retore them or extracting a
tooth.
 CLINICAL SCENARIO OF INTEREST

Deep proximal lesions with subgingival

margins exceeding the CEJ

Challenges
• Limited access
• Rubber dam slippage over the margin, and subsequent persistent saliva, crevicular
fluid and blood leakage
 CONVENTIONAL APPROACH
• Orthodontic extrusion
• Surgical exposure of the cervical margin
• A combination of both techniques

Apical displacement of supporting tissues to

access the subgingival margin and obtain
adequate space for the establishment of biological
width (BW)
 DRAWBACKS OF SURGICAL CROWN
LENGTHENING
• CL IS USUALLY EXTENDED TO THE ADJACENT TEETH
AND NOT LIMITED SOLELY TO THE TARGETED TOOTH
FOR HARMONIOUS OSSEOUS AND GINGIVAL
CONTOURS. HOWEVER, IT MAY LEAD TO LOSS OF
BONE SUPPORT IN THE ADJACENT TEETH RESULTING
IN ESTHETIC CONCERNS SUCH AS LONG CLINICAL
CROWNS, FLATTENED PAPILLAE, AND BLACK
TRIANGLES

• MAY CAUSE FURTHER ATTACHMENT LOSS AND

EXPOSURE OF ROOT CONCAVITIES AND FURCATIONS
TO THE ORAL ENVIRONMENT
• DENTIN HYPERSENSITIVITY,
The final position of the gingival margin post-
recovery is affected by factors such as
• The immediate post-suturing position of flap margin
• Amount of osseous resection
• The experience of clinicians
• Gingival biotype
• Inter-individual variations of biologic width
• Post-surgical bone remodeling
• Healing time for maturation and stability of periodontal tissue
must also be considered before placement of a permanent
restoration in the aesthetic areas. (delaying the delivery of the
final restorations)

• Debate continues as to whether a non-invasive elevated margin

technique or surgical CL is the better strategy facilitating the
placement of large direct composite resin restorations

• Though a conservative approach is often advocated, it fails in

situations that demand change in the shape of tissues around
the tooth for restoration. Sarfati 2018
 The concept of cervical margin relocation
(CMR) Dietschi D, Spreafico R.
1997
The concept of “cervical margin relocation”( CMR) or “proximal
box/margin elevation” has been proposed for the restoration of
proximal carious lesion that extend within the connective tissue
attachment. This technique suggests avoiding a crown
lengthening procedure by placing a direct composite
restoration extending within the connective tissue attachment.
The composite material is then prepared to incorporate a
coronal, supragingival finish line for the placement of another
direct or indirect restoration.
 202
1 characterize the tissue
• No histological evidence is available to
response to CMR.
• Temporary detachment of the junctional epithelium is followed by
reattachment in areas not covered by restoration margins
• When supracrestal connective tissue attachment is removed,
histologic changes do occur and cause an apical shift and
reestablishment of the connective tissue attachment.
• While these histologic changes occur irrespective of the adopted
dental material, the marginal tissue reactions appear to be
determined by the type of restorative material.
 2021

Within the limited available evidence, crown lengthening

(CL) surgery is successful for long-term retention of teeth
DME, in conjunction with indirect restorations, has a better
survival ratio compared to CL.
BIOLOGICAL BACKGROUND
BIOLOGIC WIDTH / SUPRACRESTAL TISSUE
ATTACHMENT
• The biologic width is defined as the dimensions from the
most coronal portion of the epithelial attachment to the
most apical portion of the connective tissue attachment.

• The marginal compartments of the periodontium have

been analyzed and debated for several decades.
(Schroeder & Listgarten 2003)

• Epithelium attachment is weaker than the

connective tissue attachment because the former is
a hemidesmosomal attachment on the root surface,
while the later is made of horizontal collagen fibres
inserting into the cementum on one side and into Gargiolo et al. 1961
the connective tissue on the other.
 Epithelial response to violation

We assume that during wound healing an epithelial reattachment may

have taken place on both the cementum and the apical parts of the
composite resin surface. After iatrogenic detachment resulting from
surgical or restorative procedures, wound healing takes place, involving
hemidesmosomes and the restructuring of the basal lamina under the
influence of fibrin. It is known that epithelial attachment is not specific for
one surface structure. It is capable of being formed on enamel, cementum,
afibrillar cementum, and cuticle. Stern 1981
The epithelium has a superior adaptive capability; it is
the only tissue that obtains attachment alongside the
material. Martins et al. 2007 (composite resin, resin-
modified glass ionomer, both materials interfered with
the development of new bone and the connective
tissue attachment process.)

Therefore, when it comes to subgingival restorations

that compromise the integrity of STA, concerns should
focus on the reaction of the connective component of
STA instead of the epithelial one
• There was a high variability regarding the epithelial attachment ranging from
1- 9mm whereas the connective tissue attachment remains relatively
constant. Schmidt et al.

• No“magic number” of the biologic width can be rcommended

• Factors affecting the biologic width:

 Tooth type
 Tooth site
 Presence of restorations
 Presence of periodontal disease
 Healing time after surgical CL
The physiological function of the biologic width is that of a protective barrier for the
subjacent periodontal ligament and the supporting alveolar bone from the attack of the
pathogenic biofilm

There is significant intra- and inter-individual variability in the dimensions of the biologic
width.

A “magic number” for the biologic width as a treatment objective cannot be recommended,
as
the use of mean values could mask the actual clinical situation.

Mean values of the biologic width obtained from two meta-analyses ranged from 2.15
to 2.30 mm.
BIOLOGICAL WIDTH/ SUPRA-CRESTAL ATTACHED TISSUES
 Normal Crest High Crest
•Mid-facial measurement of 3mm, • Mid-facial& Proximal measurement
Proximally 3-4.5mm. <3mm.
•85% of the Population. • 2% of the population.

https://www.redrocksoralsurgery.com/files/2014/03/Tissue-Management-in-Restorative-Dentistry.pdf
 Low Crest

•Mid- facial measurement

>3mm and Proximally
>4.5mm.
•13% of the population.

Stable Low Crest Un-stable Low Crest

• Sulcus depth is • Sulcus Depth is

less than more than
Attachment Attachment
apparatus in apparatus in
dimension. dimension.

•Liable to recession.

https://www.redrocksoralsurgery.com/files/2014/03/Tissue-Management-in-Restorative-Dentistry.pdf
NORMAL‐CREST PATIENTS: THIS CATEGORY COMPRISES THOSE PATIENTS THAT HAVE A MIDFACIAL MEASUREMENT OF
3.0 MM AND A PROXIMAL MEASUREMENT OF4.5 MM. NORMAL CREST OCCURS APPROXIMATELY 85% OF TIME. IT IS
THEORIZED THAT A CROWN’S MARGIN IS BEST PLACED NO CLOSER THAN 2.5 MM FROM THE ALVEOLAR BONE. HENCE,
ACCORDINGLY, A CROWN MARGIN PLACED 0.5 MM SUB-GINGIVALLY WILL BE TOLERATED WELL IN THE LONG RUN.
HIGH‐CREST PATIENTS IN THIS CATEGORY, THE MIDFACIAL MEASUREMENT IS <3.0 MM, WHEREAS THE PROXIMAL
MEASUREMENT IS ALSO <3.0 MM. THIS IS A RARE FINDING AND OCCURS ONLY IN 2% OF THE POPULATION. HERE, IT IS
NOT POSSIBLE TO PLACE AN INTRA-CREVICULAR MARGIN AS IT WILL BE TOO CLOSE TO THE ALVEOLAR BONE LEADING
TO CHRONIC INFLAMMATION AND BIOLOGICAL WIDTH IMPINGEMENT. A HIGH‐CREST SITUATION CAN OCCUR IF THE
INTERPROXIMAL PAPILLA IS NOT SUPPORTED, AND IT COLLAPSES FOLLOWING AN EXTRACTION.
LOW‐CREST PATIENTS IN THIS CATEGORY, THE MIDFACIAL MEASUREMENT IS >3.0 MM, WHEREAS THE PROXIMAL
MEASUREMENT IS >4.5 MM. IN SUCH A SITUATION, PATIENTS ARE MORE PRONE TO RECESSION FOLLOWING THE
PLACEMENT OF AN INTRA-CREVICULAR CROWN MARGIN. OCCURS IN 13% OF THE POPULATION
LOW CREST, STABLE OR UNSTABLE THE LOW‐CREST ATTACHMENT IS MORE COMPLEX AS NOT EVERY PATIENT
RESPONDS THE SAME TO AN INJURY TO THE ATTACHMENT APPARATUS. THE DIFFERENCE LIES IN THE DEPTH OF THE
SULCUS WHICH CAN HAVE A WIDER
RANGE. HENCE, THE LOW‐CREST ATTACHMENT IS FURTHER DIVIDED INTO STABLE AND UNSTABLE ATTACHMENTS. TO
DIAGNOSE A PATIENT AS STABLE OR UNSTABLE, SULCUS PROBING AS WELL AS BONE SOUNDING HAS TO BE DONE.
EVIDENCE-BASED
SEQUALAE OF
BIOLOGIC WIDTH
VIOLATION
Animal studies provide histologic evidence that infringement within the
supra-crestal connective tissue attachment is associated with
inflammation and subsequent loss of periodontal supporting tissues,
accompanied with an apical shift of the junctional epithelium and supra-
crestal connective tissue attachment.
• Teeth with biological width invasion, on the proximal sites, observed
clinically and radiographically. 122 proximal sites were evaluated, 61 in
the test group (biological width invasion) and 61 in the control group
(adequate biological width).
• The invasion of the biologic width was diagnosed when the distance
from the gingival margin of restoration to the bony crest was less than 3
mm.
• Intrabony defect and bone crest level, as well as, their vertical and
horizontal components were radiographically evaluated when present.
• Plaque index, bleeding on probing, probing depth, gingival recession
height, keratinized gingival height and thickness, and clinical attachment
level were clinically evaluated.
A statistically significant relationship was
found between bleeding on probing and
gingival recession in patients who presented
intra-bony defects due to the invasion of
biological width, which may be also related to
the thickness of the keratinized gingiva.
(gingival phenotype)

Correlation between the presence of width

invasion and the decrease in the level of
the bone crest observed radiographically.
 Biologically
The international journal of periodontics and restorative dentistry
driven crown
2021
lengthening
approach
CONSISTENT BONE REMOVAL IS ASSOCIATED WITH MANY
PROBLEMS SUCH AS REDUCTION OF THE SUPPORT OF THE
TREATED TEETH, BONE REMOVAL FROM NEIGHBORING TEETH,
INVASION OF SENSITIVE AREAS LIKE FURCATIONS.
REDUCTION IN SUPRA CRESTAL DIMENSION AFTER CROWN
LENGTHENING AND A POST-SURGICAL CRESTAL BONE
REMODELING/RESORPTION IS EXPECTED AFTER OSTECTOMY
AND ROOT INSTRUMENTATION. (DEAS ET AL. 2014, LANNING ET
AL. 2003)
 Biologically
The international journal of periodontics and restorative dentistry driven crown
2021 lengthening
approach
THE NOVEL CONCEPT OF MINIMAL SUPRA- CRESTAL
TISSUE ATTACHMENT WIDTH, REDUCING SURGICAL
INVASIVENESS AND OSTECTOMY IN PARTICULAR.
THE CLINICAL REFERENCE TO DETERMINE THE 2.5-MM
SPACE WAS THE CORONAL PORTION OF THE SUPRA-
CRESTAL CONNECTIVE TISSUE, NOT THE BONE CREST,
WHICH IS REPORTED IN MOST OF THE PUBLISHED
STUDIES.
CROWN LENGTHENING WITH MINIMAL OR NO
OSTECTOMY RESULTED IN HEALTHY PERIODONTAL
CONDITIONS AT 1 YEAR FOLLOW-UP.
PERIODONTAL TISSUE RESPONSE TO
DME
 The twostep R2-
C Frese D Wolff HJ Staehle Critical review technique (step one:
PBE; step two: direct
composite resin
restoration). A critical
review is given on the
consistency of the
dogma of biological
• On the basis of our clinical observations, itwidth.
is not possible to draw any
conclusions about epithelial reattachment on a plain resin composite
surface.

• It is assumed that the extent of biological width violation plays a

role in the biological reaction of soft and hard tissues: limited
proximal area versus complete circumferential margin.

• Distinct oral hygiene training (including the use of accurately fitting

interdental brushes) in patients with occluso-proximal restorations
 2018

A novel approach to extrapolate results obtained during root coverage

procedures on restored roots to Stern 1981 hypothesize the nature of healing
of interproximal attachment tissue on a proper bonded material during
DME.
Case presentation of 3 cases with DME, 1 year or more follow –up with no
signs of inflammation or bone loss.
From a clinical point of view, DME seems to be well tolerated by
the periodontium when a good bonding with proper isolation is
performed leading to very few or no signs of inflammation.

From a histologic point of view, it is clear that no connective

tissue can be obtained on the material and that DME did not lead to
recreation of a normal periodontal attachment but to a different
biologic width composed of a long junctional epithelium and a slight
connective attachment below the material.

This situation seems healthy and well-tolerated

Further clinical and histologic studies are needed to confirm this

conclusion
 2017

Group 1 corresponded to the interproximal margin in which CMR was performed

Group 2 to the other interproximal margin in which the crown was luted directly to dental
structures.

1. Bleeding on Probing (BoP) on posterior indirect restorations with one interproximal

margin relocated cervically.
2. Possible correlation between depth of the interproximal margins and BoP.
 2017

When the margin-bone crest distance was considered, it was noticed that in Group 1 samples,
13 margins of 19 were located at a distance of 2 mm from the bone crest and in Group 2 in 6
of 11 cases. (x-ray was no standardized).

Group I Group II
BOP 53% 31.5%

Higher incidence of BoP can be expected around teeth treated with the concept
of CMR and in coincidence with deep margins placed at or closer than 2 mm
from the bone crest.
• Eight healthy patients with a residual strategic tooth needing
endodontic therapy, and post-and- core restoration
• Direct margin relocation with composite resin
• Three months after marginal relocation, the secondary flap was
harvested after crown lengthening , and stained to analyze the
inflammation degree.

• A slight trend of increased histological inflammation in treatment sites

compared with control sites but not statistically significant.
2019
 201
99

They evaluated the clinical performance of 197

indirect restorations with DME in a 12-year time span.
A 95.9% overall survival rate was identified, and
among the eight failures, five of them referred to
recurrent proximal decays.
 The International journal of periodontics & restorative dentistry · January
2016

Split-mouth study.
Test group (restorations were placed trans-surgically, access was gained
by sulcular releasing incisions, the cervical margin of the cavity was at a
distance less than 3 mm to the bone crest)
Control group (CL by apically displaced flap and bone removal)
Randomized clinical study showed that subgingival proximal restorations
impinging on BW under a strict plaque control regimen yielded a similar
plaque index, probing depth and bleeding on probing with SCL groups
after six months.
DECISION MAKING PROCESS
 European journal of esthetic dentistry : official journal of the
European Academy of Esthetic Dentistry, The · March 2010

The proposed classification is based on two decision-making parameters

in clinical order:
1) Technical-operating parameter: possibility of a correct isolation of
the field
with rubber dental dam
2) Biological parameter: measuring the distance between the cleansed
cervical margin and periodontal attachment, or the bone crest, with a
periodontal probe and radiography.
 THREE DIFFERENT CLINICAL
SITUATIONS
Grade 1 Grade 2
The rubber dam, correctly The rubber dam does not allow a
sheathed in the sulcus, is correct isolation of the field but the bi
sufficient to show cervical ologic width is respected (distance
margin with an adequately between margin and connective
prepared cavity attachment > 2 mm, or between
margin and bone crest > 3 mm).

Grade 3
The cavity cervical margin (following carious lesions or coronal fracture)is
subgingival with violation of the biologic width (distance between margin
and connective tissue attachment < 2 mm, or between margin and bone
crest < 3mm).
Grade 1 Grade 2 Grade 3
Surgical exposure of
the margin, removal of
Coronal relocation of
a wedge of soft inter-
the margin using
dental tissue. Using
flowable composite
flowable composite of
with a maximum Surgical crown
0.5mm thickness at
thickness of 1 to 1.5 lengthening
the cervical margin
mm, followed by
level fol lowed by
buildup, preparation,
buildup, preparation,
and impression.
and immediate
impression.
 The 7 most common clinical scenarios in molars with class II lesions ever
deeper were examined.
This includes both the type of restoration (direct or indirect) and the
management of the cavity margin, such as the need for deep margin
elevation (DME) or crown lengthening.
 Whenever we can use a matrix that allows raising the margin
predictably, we can perform a DME.
In cases with invasion of the connective tissue or bone crest or
those with deeper margins, crown lengthening surgery is
indicated (whenever periodontally possible), as an attempt to
achieve the highest possible long-term success of the
restoration.
2022
2022
CONCLUSION
 2022
CONCLUSION
S
• The epithelium has a superior adaptive capability; it is the only tissue
that obtains attachment alongside the material.

• Therefore, when it comes to subgingival restorations that compromise the

integrity of STA, concerns should focus on the reaction of the connective
component of STA instead of the epithelial one. (Ghezzi et al. 2019)

• In the case of a deep subgingival lesion, it is not possible for the clinician
to define whether it remains within the epithelial attachment or whether
it invades the connective tissue.
 2022 CONCLUSION
S
• When a rubber dam can be placed, the working field is assumed to be
limited within the epithelial area, and thus surgical intervention is not
needed.

• In the case of connective tissue invasion, the field technically cannot be

isolated and surgical procedures are required.

• Whether a rubber dam can be placed after creating a flap, ostectomy is

not necessary. However, it is required when, after the flap opening, the
depth of the caries does not permit proper isolation.
 2022 CONCLUSION
S
• For the time being, DME should be applied with
caution respecting three criteria:
1. Capability of field isolation.
2. The perfect seal of the cervical margin provided by
the matrix.
3. No invasion of the connective compartment of BW
Thank you