CLINICAL RESEARCH

Deep margin elevation

A case report study

Rijkje A. Bresser, MSc

University Medical Center Groningen, University of Groningen, Center for Dentistry
and Oral Hygiene, Department of Restorative Dentistry and Biomaterials, Groningen,
The Netherlands

Lucas Z. Naves, DMD, PhD

Lecturer, Department of Restorative Dentistry and Biomaterials, University Medical Center
Groningen, University of Groningen, The Netherlands

Stephan A. M. van der Made, MDT

Dental Laboratory, Kwalident Dental Studio, Beilen, The Netherlands

Marco S. Cune, DMD, PhD

Professor, Department of Restorative Dentistry and Biomaterials, University Medical
Center Groningen, University of Groningen, The Netherlands
St. Antonius Hospital, Department of Oral Maxillofacial Surgery, Prosthodontics and
Special Dental Care, Nieuwegein, The Netherlands
University of Utrecht, University Medical Center Utrecht, Department of Oral Maxillofacial
Surgery, Prosthodontics and Special Dental Care, Utrecht, The Netherlands

Marco M. M. Gresnigt, DMD, PhD

Head, Department of Restorative Dentistry and Biomaterials, University Medical Center
Groningen, University of Groningen, The Netherlands
Martini Hospital, Department of Special Dental Care, Groningen, The Netherlands

Correspondence to: Rijkje A. Bresser, MSc

Department of Restorative Dentistry and Biomaterials, Center for Dentistry and Oral Hygiene, University Medical
Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands;
Tel: +31 6 13373723; Email: [Link]@[Link]

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 BRESSER ET AL

Abstract reduce bacterial accumulation and reduce the inci-

dence of secondary caries as well as maintain peri-
Deep subgingival margins are a much-debated topic odontal health. The present case report aims to pro-
in adhesive and restorative dentistry. The hydrophobic vide a step-by-step overview of the DME technique
trait of direct composite resin materials challenges the when applied in combination with a partial indirect
restorative procedure of cavities with deep subgingival glass-ceramic restoration and also provides clinical
margins since isolation is complicated. A correct indi- guidelines to tackle deep subgingival cavities. The indi-
cation for a deep margin elevation (DME) treatment is cation for a DME and the selection of appropriate
the key to its clinical success, and adequate adapta- materials are explained, supported by the literature.
tion of the DME is crucial to its clinical performance.
An adequate adaptation of the DME may potentially (Int J Esthet Dent 2023;18:142–160)

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CLINICAL RESEARCH

Introduction time in deep and large cavities is often diffi-

cult due to proximal concavities at the cer-
Class II restorations show an annual failure vical part of the cementoenamel junction
rate of 4.0% to 4.9%, which implies that (CEJ).11,12
nearly half of composite resin restorations When morphology, particularly proximal
need replacement within 10 years.1,2 The anatomy and its emergence profile, be-
longevity of direct composite resin restor- comes more difficult to restore by means of
ations depends on patient-, tooth-, and a direct restoration, partial indirect restor-
operator-related factors. These factors are ations of glass-ceramic material are a good
direct predictors for restoration success or alternative. Data derived from a systematic
failure.2-5 The number of included surfaces review and meta-analysis by Morimoto et
in direct composite resin restorations seems al13 exhibit low failure rates of partial
to have an influence on the longevity of the glass-ceramic restorations (PGCRs). Exten-
restoration, since the literature reports sig- sive research has been conducted on the
nificantly more failures in three-surface or longevity of inlays and onlays, with reported
multi-surface compared with two-surface survival rates of approximately 96% after
restorations.6,7 Moreover, there is also a cor- more than 10 years.13-15
relation between older patients and higher Glass-ceramic restorations can be ad-
failure rates.2,4,7 The adhesive protocol and hesively luted to the tooth substrate. The
composite resin materials used are other adhesive strength is significantly enhanced
aspects that should be considered when in- by the application of immediate dentin seal-
vestigating the reasons for direct composite ing (IDS) to the exposed dentin surface prior
restoration failures. Minor differences in to restorative bonding.16,17 Clinical studies
material composition such as filler volume evaluating PGCRs in combination with IDS
and polymerization shrinkage8,9 may affect show good survival rates over a longer
the clinical behavior of composite resin period of time.17,18
restorations.6 Lastly, the operator is deemed Cavities can extend in both the bucco-
influential in the increase of restoration fail- lingual and occlusocervical directions, often
ures in terms of skills, experience, and reaching beyond the CEJ. Deep subgingival
accuracy.1,4,7 margins of large cavities pose potential
Secondary caries is considered the pre- problems and operative challenges regard-
dominant cause of restoration failure and ing proper isolation and the maintenance of
seems to occur more often in direct com- periodontal health. Proper isolation of the
posite resin compared with amalgam restor- cavity using rubber dam is important during
ations.10 However, the evidence for this pre- the adhesive application of direct compo-
sumption is considered of low quality since site resin materials.19,20 Deep dentin margins
the studies included in this meta-analysis10 of cavity outlines complicate isolation with
are heterogenous and the conclusions had rubber dam and might add to the reduced
to be drawn from studies with a high risk of longevity and higher failure rates of margins
bias and inconsistency in the results. in dentin.21,22 In vivo evidence to support the
Cervical secondary caries of a class II benefits of rubber dam is scarce, and often
composite restoration is a common clinical rubber dam seems to be not as beneficial as
situation requiring even deeper subgingival relative isolation using cotton rolls.23,24 How-
margins in the restoration. Managing a ever, in vitro research has shown the ad-
proper contact point, good emergence pro- verse effects of salivary contamination with
file, and adequate marginal seal at the same the adhesive system of adhesive materials in

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 BRESSER ET AL

terms of adhesive bond strength deteriora- and involving 197 posterior restorations
tion in the absence of rubber dam isola- reported a survival rate of 95.9% with a
tion.25 Recently, a systematic review and standard error (SE) of 2.9%.35
meta-analysis showed low-certainty evi- The DME technique is operator sensitive.
dence for lower failure rates in restorations The use of magnification,36 rubber dam iso-
fabricated with the use of rubber dam. lation,20,22 and a gold standard adhesive sys-
Moreover, rubber dam isolation increases tem37 are highly recommended. DME
the visibility of the operatory field, which is should be brought to the attention of and
beneficial in case of deep cavity outlines in taught to general practitioners, since deep
order to check the marginal adaptation of cavity outlines are a common situation in
the applied matrix system.26 clinical practice.
Another problem with a subgingival mar- The aims of the present case report are:
gin is a potential violation of the biologic To state when a DME is indicated and
width. Invasion of the biologic width occurs what materials to use.
when a restoration margin is located in To provide a step-by-step overview of the
close proximity to the alveolar bone crest, DME technique and give clinical guide-
inducing an inflammatory response of the lines to tackle deep subgingival cavities.
gingival tissue.27,28 If a margin invades the To provide a protocol on how to adhesive-
biologic width, a surgical crown lengthen- ly bond a PGCR after performing a DME.
ing (SCL) procedure is advised to reestablish
adequate distance of the margin to the Case 1
alveolar bone. This technique is effective to
counteract the periodontal inflammatory Indication and treatment planning
response; however, possible furcation in-
volvement,29 enlarged approximal access, The patients in the present case report were
and the difficulty in predicting the location treated by one of the authors (MMMG) at
of the gingival margin should be thoroughly the center for special dental care of the
considered.30,31 Moreover, the impression Martini Hospital, Groningen, The Nether-
procedure is also less of a challenge after lands. Written informed consent was ob-
surgical intervention since the cervical tained from both patients for the use of all
margin is exposed. clinical photographs, radiographs, and im-
Another minimally invasive and less pressions for the field emission gun scan-
time-consuming approach would be to ning electron microscopy (FEG SEM) images.
perform a deep margin elevation (DME),32 In October 2021, a 28-year-old female
which elevates the margin of a subgingival patient presented with secondary caries on
cavity to a supragingival position using a di- the mesial side of the maxillary left second
rect composite resin material. DME facili- molar (Fig 1). The old composite restoration
tates isolation, impression making, and the had been in function for 8 years, which is
adhesive luting procedure of a PGCR.33 congruent with the previously mentioned
With close consideration of the periodontal survival rates of direct composite restor-
properties, a DME is only indicated in cavi- ations.1,2 A radiograph confirmed the diag-
ties with margins extending below the gingi- nosis of secondary caries beneath the
val tissue, thereby complicating isolation, mesial direct composite restoration and
although biologic width is not invaded.27,34 provided some insight into the extent of the
Recently, a retrospective clinical study with cavity (Fig 2). Treatment of the caries lesion
a mean follow-up of approximately 5 years was indicated to prevent progression of the

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CLINICAL RESEARCH

Fig 1 Initial situation of secondary decay on the mesiopalatal side of the Fig 2 Preoperative radiographic image of secondary
maxillary left second molar. caries.

decay toward the pulp. If tooth material is the preparation procedure. The teeth in the
lost, one can opt for an indirect restoration. maxillary left quadrant were isolated using a
The cavity was expected to extend subgin- clamp (KSK 26; Dentech, Tokyo, Japan) on
givally and beyond the CEJ, thereby compli- the second molar and rubber dam (Non-
cating isolation and restorative procedures. Latex Heavy Dental Dam; Isodam, Michigan,
This molar cannot be repeatedly restored USA). The rubber dam was inverted on the
after this restorative procedure due to the entire quadrant to prevent any leakage of
severity of the deep cervical part of the cav- intraoral fluids to the operative field.20
ity. It was therefore proposed to treat this
medium- to large-sized cavity with a DME Preparation
and a PGCR to optimally restore the tooth
and increase its life span to a maximum. The old composite restoration was removed
Firstly, infiltration anesthesia was given using a pear-shaped green coarse diamond
(1.2 ml Ultracain D-S Forte; Sanofi, Frankfurt, bur (830L; Komet Dental, Lemgo, Germany)
Germany) and the shade-taking procedures but leaving the marginal ridge intact to pro-
for the PGCR were performed using a tect the neighboring tooth during prepar-
cross-polarized photograph with a gray card ation and caries removal (Fig 3). The approx-
as reference.38 The entire treatment was imal wall of composite was safely removed
performed with the aid of an operative using an ultrasonic device with a mesial
microscope (OPMI Pico; Zeiss, Jena, Ger- divergent diamond-coated tip (SONICflex;
many) using 4-25× magnification. A putty KaVo Dental, Biberach, Germany). After the
impression (Provil Novo Medium fast set; removal of the approximal composite, the
Heraeus Kulzer, Hanau, Germany) with de- caries lesion was clearly visible and extend-
tailed liner (Provil Novo Light fast set; ed below the rubber dam, complicating iso-
Heraeus Kulzer) was made to provide the lation of the operatory field (Fig 4). A round
patient with a temporary restoration after carbide bur (H1SE.014; Komet Dental) was

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 BRESSER ET AL

used to clean the carious dentin, and Teflon

tape was packed at the cervical part of the
cavity to maintain adequate isolation. Caries
removal was checked with a caries detector
dye (Caries Detector; Kuraray Dental, Tokyo,
Japan) and the cavity was continuously
monitored until a clean peripheral seal was
visible (Fig 5). After caries removal, the cavity
was further cleaned by sandblasting 30-μm
Al2O3 particles on the tooth substrate to Fig 3 Accessing the caries lesion and leaving the marginal ridge intact.
later enhance the shear bond strength of
the composite resin to the dentin surface39
(Aquacare; Velopex, London, UK), while the
neighboring tooth was protected with a
sectional matrix shield (A–M, Palodent;
Dentsply Sirona, Pennsylvania, USA). It is of
the utmost importance in this treatment
phase to assess the distance from the cervi-
cal cavity outline to the marginal alveolar
bone, to determine whether the margin of
the restoration might interfere with the bio- Fig 4 The caries lesion extends below the CEJ and rubber dam isolation is
logic width. A bone-sounding procedure difficult to achieve.

was performed by placing a periodontal

probe along the mesial side of the tooth,
and the average distance of 2.04 mm for
the biologic width was respected according
to Gargiulo et al.27 Alternative treatments
such as SCL procedures should be con-
sidered if there is any possible jeopard-
ization of the biologic width.

Immediate dentin sealing

Fig 5 The cleaned cavity with proper isolation maintained cervically due to the
packed Teflon tape.
The Teflon tape was removed after the cav-
ity preparation to facilitate matrix placement.
Several matrix systems have been proposed
to perform DME.40,41 A recent article intro-
duced the use of a perforated, contoured
metal matrix (Tor VM matrix; TOR VM,
Heidelberg, Germany) with excellent marginal
adaptation and a good emergence profile.42
In the cases reported here, a Tor VM matrix
was used to elevate the subgingival margin
to a supragingival position (Fig 6). Note the Fig 6 Clinical situation after Tor VM matrix placement. The cavity was cleansed
marginal seal and emergence profile in the with water to see whether the matrix was placed correctly, which explains the
deep cavity, ensuring proper isolation. After remaining liquid in the cavity.

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CLINICAL RESEARCH

surface was air-dried for 3 s, without desic-

cating the dentin, and a primer was rubbed
into the dentin for 15 s (OptiBond FL Primer;
Kerr) and lightly air-blown for 5 s. A thin layer
of adhesive (OptiBond FL Adhesive; Kerr)
was carefully applied onto the dentin sur-
face with a microbrush and spread with a
dental probe.16 The deep enamel in the
mesial box was also covered with adhesive
to ensure proper bonding of the DME to
Fig 7 Injecting flowable composite with an elongated tip.
the tooth substrate. The adhesive layer was
photopolymerized using a high-power
curing unit (> 1000 mW/cm2) (SmartLight
Pro; Dentsply, Milford, USA) for 20 s to
complete IDS.

Deep margin elevation

After IDS, a small amount of flowable com-

posite (G-aenial Universal Injectable; GC,
Leuven, Belgium) was injected into the deep
cavity to elevate the deep subgingival mar-
gin to a supragingival position. The tip of the
injectable composite was in contact with
the cervical outline of the cavity to ensure
that no air bubbles were imbedded in the
Fig 8 Finishing the cervical margin of the composite resin to the tooth substrate
DME (Fig 7). The flowable composite was
with an EVA handpiece (LTA-30/2 Diamond White).
photopolymerized for 40 s to ensure proper
polymerization of the composite resin ma-
terial in the deep cavity. The Tor VM matrix
was removed and the composite resin ad-
justed and polished at the buccal and pala-
tal sides using an EVA handpiece to ensure
proper adaptation of the composite resin to
the tooth (Fig 8). Note the position of the
placement of a wedge to ensure marginal rubber dam at the cervical part of the cavity
adaptation of the matrix, IDS was applied to before and after the DME. Isolation was re-
the exposed dentin surface to enhance the established and a predictable adhesive tech-
bond strength of the restoration to dentin.43 nique could be applied at the placement
A three-step etch-and-rinse system (Opti- appointment, which is one of the main
Bond FL; Kerr, Orange, CA, USA) was used benefits of DME (Fig 9). A radiograph was
to perform IDS. First, the enamel and dentin taken to verify the adaptation of the DME to
surfaces were etched for 30 s and 10 s, re- the cervical outline (Fig 10) because the
spectively, with 37% phosphoric acid (Ultra- clinical success of the restoration is directly
Etch; Ultradent, St Louis, MO, USA), then related to the marginal seal and marginal
rinsed thoroughly with water for 15 s. The adaptation of the DME to the tooth. A

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 BRESSER ET AL

proper marginal seal and adaptation reduces

bacterial accumulation, prevents second-
ary decay, and contributes to periodontal
health.28,44
Next, it was important to check whether
the IDS covered all the exposed dentin but
not the enamel of the preparation. It is very
difficult, or even impossible, to only remove
IDS from the enamel and not from the den-
tin structure. Therefore, a very small part of
Fig 9 Result of the preparation and DME on the mesial aspect.
dentin was exposed or left uncovered with
the IDS. Any adhesive or composite rem-
nant on the enamel surface was removed
using a polisher (Brownie; Shofu Dental,
Ratingen, Germany). This step is particularly
important because it will allow etching and
bonding to ‘fresh’ etched enamel when lut-
ing the ceramic restoration at the final stage
of the restoration placement. The marginal
sealing obtained by bonding to the non-
obstructed enamel surface will provide a
strong and stable bond strength to reinforce
the chain effect,45 which may help to pro-
tect the entire outline perimeter of the res-
toration. When all the surroundings have a
stable bonding to enamel, it may help to
Fig 10 Midoperative radiograph to check the marginal adaptation of the
overcome the limitations of bonding to
flowable composite to the cervical dentin.
dentin in a deep proximal area.21
Additionally, glycerin gel (K-Y; Johnson &
Johnson, Heidelberg, Germany) was applied.
The resin was polymerized again to elimi-
nate the oxygen-inhibition layer. An impres-
sion was made using an addition silicone
material with two viscosities in duplicate
(Aquasil Medium and Light Body; Dentsply
Sirona, Pennsylvania, USA). The macro as- enamel shown in Figure 11d; considering
pect of the cavity after IDS and DME can be this, the area should also be included when
seen in Figure 11a and b. Higher magnifica- using the polisher (step described above) to
tion (871×) of the elevated proximal box can clean the enamel margins. Thereafter, a
be seen in Figure 11c. The composite sur- self-curing provisional restoration (Protemp;
face at the proximal margin of the cavity 3M ESPE, Seefeld, Germany) was made with
should also be free of any surface oblitera- the putty impression to protect the tooth
tion to avoid any impairment to the bonding and reduce the risk of mesial migration and
procedures at this critical area. The compo- eruption of the prepared tooth and its
site should be as clean and free of debris adjacent elements. It was cemented with a
and contaminants as possible, like the polycarboxylate material (Durelon; 3M ESPE).

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CLINICAL RESEARCH

D
fco
en
co
C
ad

co
a b 1 mm c 100 μm d 50 μm

Fig 11 (a) Clinical situation from where the replica impression was taken. Note the clean cavity after phosphoric acid etching, ready for the
bonding procedure to fixate the indirect restoration. (b) SEM magnification (21x) equivalent to the clinical image shown in ‘a’. (c) Close-up
magnification (871x), indicating the bottom of the mesial proximal cavity, showing the composite (co) of the DME and its boundary to the
flow composite (fco) also used during the IDS technique. (d) Close-up magnification (2007x) showing the DME margin to the enamel surface
(co: composite; fco: flow composite; ad: adhesive bond; en: enamel).

Adhesive luting of the partial and form small porosities within the ceramic,
glass-ceramic restoration which allows a good adhesive bond forma-
tion. The hydrofluoric acid was rinsed off in
Intraoral fitting of the PGCR a bath of neutralizing powder (Neutralizing
The PGCR was fabricated and glazed fol- Powder; Ivoclar Vivadent, Schaan, Liechten-
lowing the manufacturer’s guidelines. The stein), and the surface of the restoration was
restoration was checked on the gypsum cleaned again with 37% phosphoric acid
cast for marginal discrepancies, mesial con- (Ultra-Etch) and an ultrasonic bath (5 min in
tact point, and occlusion prior to the pa- demineralized water) to remove the remain-
tient’s arrival. The provisional restoration ing contamination on the inside of the res-
was removed with a scaler and the patient’s toration. After cleaning the ceramic, a silane
tooth was wedged prior to fitting. The res- (Bis-Silane; Bisco, Schaumburg, USA) was
toration was fitted using glycerin gel, with applied to the surface of the restoration and
special attention given to marginal adap- dried in an oven at 100oC for 3 min. All
tation, proximal contact point, color, and surface conditioning steps of the ceramic
occlusion with the opposing arch. restoration are shown in Figure 12.

Surface conditioning of the ceramic intaglio Surface conditioning of the tooth

The glass-ceramic restoration was approved The second quadrant was then isolated with
and the intaglio surface conditioned in mul- rubber dam and the surface of the tooth
tiple steps to optimize adhesive strength. thoroughly cleaned with a hand scaler to
First, the surface was etched for 60 s with remove the polycarboxylate cement from
9% hydrofluoric acid (Porcelain Etch; Ultra- the IDS and enamel. The adjacent tooth
dent) to dissolve the superficial glass matrix was protected from conditioning using a

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 BRESSER ET AL

sectional matrix. The IDS, DME, enamel, and

uncovered dentin were conditioned by
sandblasting with silica-coated Al2O3 parti-
cles (AquaCare Cosil; Velopex) at a pressure
of 3 bar,46,47 rinsed thoroughly with water,
and air-dried in order to clean the entire a b c
preparation from possible contamination
with the polycarboxylate cement of the
temporary restoration. Thereafter, the enam-
el was etched with 37% phosphoric acid
(Fig 13a) for 30 s and rinsed thoroughly. The
surface aspect shown in Figure 13b depicts
the etched and clean surface, showing the d e f
enamel prism aspect on its topography. To
ensure proper bonding to uncovered dentin Fig 12 (a) Surface of the PGCR prior to surface conditioning. (b) 9% hydrofluoric
with IDS, a primer (OptiBond FL Primer) was acid etching. (c) Surface of the restoration after hydrofluoric acid etching.
rubbed into the preparation for 15 s and (d) Cleaning the restoration using 37% phosphoric acid. (e) Surface after 5 min in
an ultrasonic bath with demineralized water. (f) Application of silane.
lightly air-blown for 5 s. The sectional matrix
was removed and replaced with a piece of
Teflon tape to enable placement of the
glass-ceramic restoration but still prevent
adhesive conditioning of the neighboring
tooth. The IDS and DME were silanized and B
left to dry for 3 min. The filled adhesive
(OptiBond FL Adhesive) was applied to the ad en
surface of the ceramic restoration and on
the preparation, but not photocured.

Adhesive luting procedure

The indirect restoration was adhesively a b 50 μm
luted with a preheated composite resin ma-
Fig 13 (a) Selective enamel phosphoric acid etching. (b) SEM micrography
terial (HFO UD1; Micerium, Avegno, Italy).
(667x) showing the margin between the etched enamel and the adhesive sealing
The preheated composite was placed in the
(IDS) (en: enamel; ad: adhesive bond).
cavity with a slight excess and evenly distrib-
uted to ensure that all crevices were filled
during restoration placement. Then, the res-
toration was placed into the cavity and pres-
sure was applied to allow the removal of
excess composite resin from the marginal
outline (Fig 14). A hand instrument (Fissure;
LM-Arte, Parainen, Finland) was used to re-
move the excess composite prior to photo-
polymerization. Pressure application and
the removal of excess composite resin was
repeated until no more composite resin
material could be removed. The buccal and Fig 14 Excess composite resin material along the entire outline.

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CLINICAL RESEARCH

Fig 15 Excess
composite resin
removed, showing
the result after
finishing and
polishing.

Fig 16 Fluorescent
image showing the
transition between
the tooth and the
indirect restoration.

palatal sides were photopolymerized for

10 s and glycerin gel was applied to elimi-
nate an oxygen-inhibition layer. The restor-
ation was further photopolymerized for 40 s
at each side to cure the luting composite
Fig 17 Postoperative completely after the excess composite resin
radiograph to check
material was removed. The remaining ex-
for excess luting
composite cement
cess composite resin was removed with the
and the marginal use of a surgical 12D blade and a scaler. The
adaptation. outline was further optimized with the use

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 BRESSER ET AL

C
B en
en
co
co

D ce
ce
a b 1 mm c 200 μm d 1 mm

Fig 18 (a) Postoperative photograph after finishing and polishing. (b) SEM micrography (90x) showing the interface of ceramic and enamel.
A minimal interfacial luting composite can be seen (arrows). (c) SEM micrography (226x) showing a higher magnification of the same
interface, but here at the marginal ridge. Note the area of adhesive continuity (AAC) or a smooth transition among enamel/composite/
ceramic. (d) SEM micrography (97x) showing the bonding interface at the palatal–proximal site after 6 months. Images ‘b’ and ‘c’ represent a
bonding interface with and without a marginal mismatch, respectively (co: composite; en: enamel; ce: ceramic).

of an EVA handpiece and an Arkansas stone decreasing biofilm retention and promoting
bur. Then, the outline of the restoration was optimal integration with the surrounding
polished with a Brownie, EVA polishers hard and soft tissue.
(red and white), and a ceramic polisher
(CeraGloss; Edenta, Au, Switzerland) (Fig 15). FEG SEM analysis
The outline of the restoration was checked Representative clinical situations were ana-
for excess adhesive material using fluores- lyzed utilizing FEG SEM.49 An impression
cence (Fig 16). The rubber dam was re- (Aquasil Ultra-Light and Heavy Body; Dent-
moved and the occlusion checked. A final sply) was made from polyvinyl siloxane
radiograph was taken to check for excess (PVS) after cleansing the surface with absor-
cement and the marginal adaptation of the bent paper and sodium hypochlorite 0.5%.
partial indirect restoration (Fig 17), and a Impressions were poured with cold mount-
postoperative clinical photograph was taken ing epoxy resin (EpoxyCure 2; Buehler, Lake
after 3 months of clinical service (Fig 18a). Bluff, IL, USA). After final curing, the replicas
The final aspects of the bonding interface were sputter-coated with a 3-nm–thick layer
under ultra-high magnification are shown in of gold (80%)/palladium (20%, 90 s, 45 mA)
Figure 18b and c, where an area of adhesive (Balzers SCD 030; Balzers, Liechtenstein),
continuity (AAC) with a smooth transition and analyzed using a dual beam FEG SEM/
from the enamel surface to the ceramic res- FIB microscope (LyraTESCAN; Tescan, Brno,
toration can be seen.48 Figure 18d depicts Czech Republic). The evaluation focused
the marginal interface at the proximal site on marginal and surface integrity, homo-
after 6 months of clinical service. The finish- geneity, and continuity along the bonding
ing and polishing procedures are key to interface and ceramic surface (Fig 18).

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CLINICAL RESEARCH

Fig 19 Clinical pre-restorative situation of the maxillary left first Fig 20 Radiographic image to check the approximal marginal
molar. adaptation of DME to the dentin. Note the secondary caries lesion in
the second molar.

Fig 21 Clinical situation after DME and before placement of the Fig 22 Clinical situation after adhesive luting of the crown.
indirect restoration.

Case 2 she wanted to keep the tooth by all means

possible. The aim was therefore to restore
This case illustrates the applicability of DME this endodontically treated molar one last
to a more extensive caries lesion and was time by performing DME and providing the
treated entirely according to the adhesive tooth with a circumferential crown of lithium
protocol described for case 1. This female disilicate. The decay was extensive in the
patient was referred to the clinic for extrac- cervical and buccopalatal directions and in-
tion therapy of the maxillary left first molar cluded all sides of the tooth. Isolation with
(Fig 19). The poor prognosis of the molar rubber dam was not possible, and therefore,
was discussed with the patient; however, after the bone-sounding procedure, DME

154 | The International Journal of Esthetic Dentistry | Volume 18 | Number 2 | Summer 2023
 BRESSER ET AL

was performed according to the previously

described protocol using a circular matrix
(AutoMatrix; Dentsply Sirona, Charlotte, USA).
The adaptation of the DME was checked
with a periapical radiograph (Fig 20) and the
caries lesion at the mesial side of the maxil-
lary left second molar was treated with a
direct composite restoration. To clarify, no
endodontic retreatment was performed.
Impressions were made and sent to the
dental laboratory, and a crown of lithium
disilicate was fabricated. The margin of the
cavity could now easily be isolated (Fig 21)
prior to adhesive luting of the indirect res-
toration. The lithium disilicate crown was
adhesively luted to the preparation (Fig 22)
according to the previously described pro-
tocol. Marginal adaptation of the indirect
Fig 23 Radiographic image after adhesive luting of the crown.
restoration to the DME was checked with a
radiograph (Fig 23).
Although the prognosis of this endodon-
tically treated maxillary first molar is ques-
tionable, this case shows the extensive
applicability of the DME technique in very
different clinical situations with varying
levels of difficulty. The patient recently to reduce the possibility of an adverse peri-
attended a routine check-up at the dental odontal reaction. Besides the scientific and
clinic, during which it was observed that the practical indications of DME, it might be
crown and DME remained in good condi- even more important for the clinician to
tion even after a duration of 1.5 years. The weigh the benefits and costs of performing
DME technique is shown as a conservative these expensive and often time-consuming
treatment alternative for a situation where restorative procedures prior to deciding
the tooth would otherwise have to be whether the molar is worth the effort. A
extracted or subjected to more invasive prognosis of the premolar should be made
surgical treatments. prior to DME treatment, for which it is of the
utmost importance to view the entire denti-
Discussion tion in perspective. DME might be benefi-
cial, but it is relevant to discuss possible
The present case report provides a clear complications and (clinical) limitations of
protocol and indication to perform the DME the technique and the required materials.
technique and was applied in two very dis- Survival rates of direct composite resin
tinct cases. DME is indicated in preparation materials after 10 years1,2 seem significantly
outlines below the gingival tissue and for lower compared with those of PGCRs.13
which isolation is difficult. Moreover, the Given these data, clinicians doubt whether
distance from the preparation outline to placing a direct composite resin restoration
the alveolar bone should be > 2.04 mm27 below a PGCR is considered good clinical

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CLINICAL RESEARCH

practice. However, over the past several elution of monomers and initiators into the
years, strong adhesive protocols have been oral environment. It modulates the biofilm
developed and optimized to maximize ad- and activity of Streptococcus Mutans,56
hesive bond strengths of composite resin to which is one of the main bacteria causing
enamel, dentin, and glass-ceramics.16,47,50 It caries lesions. The elution/degradation of
is unknown whether these protocols were monomers and initiators results in a loss of
used in the (multicenter) retrospective studies up to 2% of the initial mass of composite
from which survival rates were calculated, resin material.57,58
and whether the doubts of clinicians are in- Besides shrinkage stress and composite
deed justified. If adhesive and curing proto- degradation, a higher surface roughness of
cols are executed accordingly, survival rates restorative materials also significantly con-
might be higher, and the adverse properties tributes to plaque formation, which might
of resin-based materials could be tackled, consequently increase the occurrence of
compared with previous studies.51 secondary caries and periodontal inflamma-
Like any dental material, composite resin tion.59,60 Due to their material properties,
has certain adverse properties. These in- composite resin materials develop bacterial
clude, among others, polymerization shrink- biofilm formation quicker than porcelain or
age and related shrinkage stress, which can gold restorations.60 Besides quicker forma-
result in restoration deterioration and failure tion, the biofilm of composite resin might
due to secondary caries or fractures.3,52 also be more viable and susceptible to sec-
Polymerization stress, as a result of poly- ondary decay compared with amalgam res-
merization shrinkage by bonding to multiple torations. Some low-certainty evidence ex-
cavity walls, can induce micro gaps of the ists to support this statement,10 while other
marginal seal and thereby disrupt the bond- evidence is scarce and outdated.61,62 More
ed interface.53 This allows bacteria and recent studies even contradict this state-
water sorption, which can result in marginal ment and cannot find a reduced secondary
staining and secondary caries.54 To reduce decay formation for amalgam restorations.63
polymerization stress, it is important to keep Supposedly, an entirely different ap-
the C-factor as low as possible by using the proach to treat extensive subgingival sec-
incremental technique, in which the com- ondary decay is possible. The biologically
posite is layered and cured in increments of oriented preparation technique (BOPT) aims
< 2 mm.55 In deep proximal cavities, it is par- to make a vertical preparation without a finish
ticularly important to be aware of the dis- line to create room for a new emergence
tance between the light curing unit tip and profile by the prosthetic crown. The surround-
the composite surface. The intensity of the ing soft tissue is modified in shape and pos-
light from the curing light is inversely pro- ition by gingival curettage, adapting to the
portional to the square of the distance be- shape of the new prosthetic emergence.
tween the light source and the surface of BOPT has been shown to provide satisfac-
the composite. Often, the dimensions of tory periodontal and restorative results of
the cavity do not allow an approximation 93.1% over 6 years.64,65 However, BOPT is
that guarantees maximal polymerization ef- entirely different to DME, and requires a dif-
fectiveness. In these situations, increasing ferent approach. DME relies on adhesive
the photoactivation time is recommended bond strength and allows the treatment to
to avoid insufficient monomer conversion.8 be minimally invasive, while BOPT relies on
Incomplete conversion of the compo- retentive strength through circumferential
site resin monomers to polymers results in preparations without adhesive bonding. The

156 | The International Journal of Esthetic Dentistry | Volume 18 | Number 2 | Summer 2023
 BRESSER ET AL

invasive nature of the BOPT approach is indications, and most of them also lack the
directly also its major disadvantage in case solid scientific evidence needed for them to
of local secondary decay, which is why DME be established as standard treatment.
was chosen as the appropriate approach in
the present case series. Conclusions
Another alternative to restore deep sub-
gingival preparations in the posterior zone In technical terms, DME is indicated in cases
might be to use partial gold restorations. in which isolation is difficult to obtain but
Gold is a predictable restorative material biologic width is not violated by the margin
with a long history of success, also in deep of the cavity. Besides technical terms, a
dentin outlines, with survival rates of 94.1% cost-benefit analysis of the clinical perspective
over more than 40 years of clinical ser- and a prognosis of the concerned tooth
vice.66,67 Only recently, a new idea was pro- prior to treatment is of the utmost importance
posed to combine gold with composite to overall clinical success. The use of mag-
resin in deep dentin cavity outlines: a direct nification while performing this treatment is
gold/composite sandwich restoration.68 highly advisable to deliver restorations with
This idea tries to enhance the life expectan- precision and close marginal adaptation,
cy of direct class II restorations by restoring which is a key factor to clinical success.
deep dentin with gold foil. Clinical studies Magnification allows the examination of the
are needed to assess whether this combina- adaptation of the matrix system to the cavity
tion of materials is a viable treatment option. margin, enables precise application of the
Such studies should focus mainly on the IDS to the dentin structure, and allows the
marginal quality and recurrent caries at the careful and complete removal of the excess
gold and composite interface. luting cement after placement.
More long-term prospective and retro- When indicated and performed meti-
spective in vivo research and randomized culously, DME is an effective adjunctive
controlled clinical trials are needed to con- treatment to the provision of PGCR in cases
clude whether DME is a reliable treatment with deep cervical margins, with a high
option for deep subgingival cavities in the chance of success.
long run. However, if resin-based materials
are applied correctly, and the degree of Acknowledgments
stress development can be controlled, dur-
able and highly esthetic direct restorations The authors are grateful to Prof Dr Y Pei, Dr
show excellent survival rates over a long D. Ribas-Gomes, and Dr E. Galinmoghaddam
period of time.69 (Applied Physics, Materials Science, Zernike
Overall, all other treatment approaches Institute, University of Groningen) for the
for severe compromised proximal cavities scientific and technical support with the
also have their limitations and contra- scanning electron microscopy (FEG SEM).

The International Journal of Esthetic Dentistry | Volume 18 | Number 2 | Summer 2023 | 157
CLINICAL RESEARCH

References
1. Laske M, Opdam NJM, Bronkhorst EM, 11. Nedeljkovic I, De Munck J, Vanloy A, 20. Browet S, Gerdolle D. Precision and
Braspenning JCC, Huysmans MCDNJM. et al. Secondary caries: prevalence, security in restorative dentistry: the synergy
Ten-year survival of Class II restorations characteristics, and approach. Clin Oral of isolation and magnification. Int J Esthet
placed by general practitioners. JDR Clin Investig 2020;24:683–691. Dent 2017;12:172–185.
Trans Res 2016:1:292–299. 12. Patras M, Doukoudakis S. Class II 21. Collares K, Corrêa MB, Laske M, et al.
2. Wierichs RJ, Kramer EJ, Meyer-Lueckel H. composite restorations and proximal A practice-based research network on the
Risk factors for failure of direct restorations concavities: clinical implications and survival of ceramic inlay/onlay restorations,
in general dental practices. J Dent Res 2020; management. Oper Dent 2013;38:119–124. Dent Mater 2016;32:687–694.
99:1039–1046. 13. Morimoto S, Rebello de Sampaio FBW, 22. Heintze SD, Rousson V. Clinical effective-
3. Rasines Alcaraz MG, Veitz-Keenan A, Braga MM, Sesma N, Özcan M. Survival rate ness of direct class II restorations – a meta-
Sahrmann P, Schmidlin PR, Davis D, of resin and ceramic inlays, onlays, and analysis. J Adhes Dent 2012;14: 407–431.
Iheozor-Ejiofor Z. Direct composite resin overlays: a systematic review and meta- 23. Cajazeira MR, De Sabóia TM, Maia LC.
fillings versus amalgam fillings for perma- analysis. J Dent Res 2016;95:985–994. Influence of the operatory field isolation
nent or adult posterior teeth. Cochrane 14. Beier US, Kapferer I, Burtscher D, technique on tooth-colored direct dental
Database Syst Rev 2014;3;CD005620. Giesinger JM, Dumfahrt H. Clinical restorations. Am J Dent 2014;27:155–159.
doi:10.1002/14651858.CD005620.pub2. performance of all-ceramic inlay and 24. Daudt E, Lopes GC, Vieira LC. Does
4. Demarco FF, Collares K, Correa MB, onlay restorations in posterior teeth. operatory field isolation influence the
Cenci MS, Moraes RR, Opdam NJ. Should Int J Prosthodont 2012;25:395–402. performance of direct adhesive restorations?
my composite restorations last forever? 15. Malament KA, Margvelashvili- J Adhes Dent 2013;15:27–32.
Why are they failing? Braz Oral Res 2017; Malament M, Natto ZS, Thompson V, 25. Aboushelib MN. Clinical performance
31(suppl 1):e56. doi:10.1590/1807-3107BOR- Rekow D, Att W. Comparison of 16.9-year of self-etching adhesives with saliva contami-
2017.vol31.0056. survival of pressed acid etched [Link] nation. J Adhes Dent 2011;13:489–493.
5. Goldstein GR. The longevity of direct and lithium disilicate glass-ceramic complete 26. Peumans M, Politano G, Van
indirect posterior restorations is uncertain and partial coverage restorations in Meerbeek B. Effective protocol for daily
and may be affected by a number of posterior teeth: Performance and outcomes high-quality direct posterior composite
dentist-, patient-, and material-related as a function of tooth position, age, sex, and restorations. Cavity preparation and design.
factors. J Evid Based Dent Pract 2010;10: thickness of ceramic material. J Prosthet J Adhes Dent 2020;22:581–596.
30–31. Dent 2021;126:533–545. 27. Gargiulo AW, Wentz FM, Orban B.
6. Lempel E, Tóth Á, Fábián T, Krajczár K, 16. van den Breemer CG, Özcan M, Dimensions and relations of the dento-
Szalma J. Retrospective evaluation of Cune MS, Almeida Ayres AP, Van gingival junction in humans. J Periodontol
posterior direct composite restorations: Meerbeek B, Gresnigt MMM. Effect of 1961;32:261–267.
10-year findings. Dent Mater 2015;31; immediate dentin sealing and surface 28. Padbury A Jr, Eber R, Wang HL.
115–122. conditioning on the microtensile bond Interactions between the gingiva and the
7. Laske M, Opdam NJM, Bronkhorst EM, strength of resin-based composite to dentin. margin of restorations. J Clin Periodontol
Braspenning JCC, Huysmans MCDNJM. Oper Dent 2019;44:E289–E298. 2003;30:379–385.
Risk factors for dental restoration survival: 17. Gresnigt MMM, Cune MS, Schuite- 29. Dibart S, Capri D, Kachouh I, Van
a practice-based study. J Dent Res 2019;98: maker J, et al. Performance of ceramic Dyke T, Nunn ME. Crown lengthening in
414–422. laminate veneers with immediate dentine mandibular molars: a 5-year retrospective
8. Ferracane JL, Hilton TJ. Polymerization sealing: An 11 year prospective clinical trial. radiographic analysis. J Periodontol 2003;
stress – is it clinically meaningful? Dent Dent Mater 2019;35:1042–1052. 74:815–821.
Mater 2016;32:1–10. 18. van den Breemer CRG, Cune MS, 30. Pilalas I, Tsalikis L, Tatakis DN.
9. Meredith N, Setchell DJ. In vitro Özcan M, Naves LZ, Kerdijk W, Gresnigt MMM. Pre-restorative crown lengthening surgery
measurement of cuspal strain and displace- Randomized clinical trial on the survival of outcomes: a systematic review. J Clin
ment in composite restored teeth. J Dent lithium disilicate posterior partial restorations Periodontol 2016;43:1094–1108.
1997;25: 331–337. bonded using immediate or delayed dentin 31. Lanning SK, Waldrop TC, Gunsolley JC,
10. Worthington HV, Khangura S, Seal K, sealing after 3 years of function. J Dent Maynard JG. Surgical crown lengthening:
et al. Direct composite resin fillings versus 2019;85:1–10. evaluation of the biological width.
amalgam fillings for permanent posterior 19. Ozer F, Blatz MB. Self-etch and J Periodontol 2003;74:468–474.
teeth. Cochrane Database Syst Rev 2021;8: etch-and-rinse adhesive systems in clinical 32. Dietschi D, Magne P, Holz J. Recent
CD005620. doi:10.1002/14651858. dentistry. Compend Contin Educ Dent trends in esthetic restorations for posterior
CD005620.pub3. 2013;34:12–14. teeth. Quintessence Int 1994;25:659–677.

158 | The International Journal of Esthetic Dentistry | Volume 18 | Number 2 | Summer 2023
 BRESSER ET AL

33. Veneziani M. Adhesive restorations in to dentin: effects of adhesive promoters, 54. Hilton TJ. Can modern restorative
the posterior area with subgingival cervical immediate dentin sealing strategies, and procedures and materials reliably seal
margins: new classification and differentiated surface conditioning. Int J Esthet Dent cavities? in vitro investigations. Part 2. Am
treatment approach. Eur J Esthet Dent 2019;14:52–63. J Dent 2002;15:279–289.
2010;5:50–76. 44. Santos VR, Lucchesi JA, Cortelli SC, 55. Bicalho AA, Valdívia AD, Barreto BC,
34. Gargiulo A, Krajewski J, Gargiulo M. Amaral CM, Feres M, Duarte PM. Effects of Tantbirojn D, Versluis A, Soares CJ.
Defining biologic width in crown glass ionomer and microfilled composite Incremental filling technique and composite
lengthening. CDS Rev 1995;88:20–23. subgingival restorations on periodontal tissue material – part II: shrinkage and shrinkage
35. Bresser RA, Gerdolle D, van den and subgingival biofilm: a 6-month evalu- stresses. Oper Dent 2014;39:E83–E92.
Heijkant IA, Sluiter-Pouwels LMA, Cune MS, ation. J. Periodontol 2007;78:1522–1528. 56. Lin NJ, Keeler C, Kraigsley AM, Ye J,
Gresnigt MMM. Up to 12 years clinical 45. Swift EJ. Enamel bonding. J Esthet Lin-Gibson S. Effect of dental monomers
evaluation of 197 partial indirect restorations Restor Dent 2003;15:325–326. and initiators on Streptococcus mutans oral
with deep margin elevation in the posterior 46. Burrer P, Costermani A, Par M, Attin T, biofilms. Dent Mater 2018;34:776–785.
region. J Dent 2019;91:103227. Tauböck TT. Effect of varying working 57. Braga RR, Ballester RY, Ferracane JL.
doi:10.1016/[Link].2019.103227. distances between sandblasting device and Factors involved in the development of
36. Eichenberger M, Biner N, Amato M, composite substrate surface on the repair polymerization shrinkage stress in resin-
Lussi A, Perrin P. Effect of magnification on bond strength. Materials (Basel) composites: a systematic review. Dent
the precision of tooth preparation in 2021;14:1621. doi:10.3390/MA14071621. Mater 2005;21:962–970.
dentistry. Oper Dent 2018;43:501–507. 47. Gresnigt MMM, Kalk W, Özcan M. 58. Ferracane JL, Condon JR. In vitro
37. Van Meerbeek B, Yoshihara K, Yoshida Y, Clinical longevity of ceramic laminate evaluation of the marginal degradation of
Mine A, De Munck J, van Landuyt KL. State veneers bonded to teeth with and without dental composites under simulated occlusal
of the art of self-etch adhesives. Dent Mater existing composite restorations up to 40 loading. Dent Mater 1999;15:262–267.
2011;27:17–28. months. Clin Oral Investig 2013;17:823–832. 59. Dutra D, Pereira G, Kantorski KZ,
38. Hein S, Zangl M. The use of a 48. Andrade O, Borges G, Kyrillos M, Valandro LF, Zanatta FB. Does finishing and
standardized gray reference card in dental Moreira M, Calichio L, Correr-Sobrinho L. polishing of restorative materials affect
photography to correct the effects of five The area of adhesive continuity: A new bacterial adhesion and biofilm formation?
commonly used diffusers on the color of concept for bonded ceramic restorations. A systematic review. Oper Dent 2018;43:
40 extracted human teeth. Int J Esthet Dent Quintessence Dent Technol 2013;36:9–26. E37–E52.
2016;11:246–259. 49. Naves LZ, Gerdolle DA, de Andrade OS, 60. Contreras-Guerrero P, Ortiz-
39. Mujdeci A, Gokay O. The effect of Gresnigt MMM. Seeing is believing? When Magdaleno M, Urcuyo-Alvarado MS, et al.
airborne-particle abrasion on the shear scanning electron microscopy (SEM) meets Effect of dental restorative materials surface
bond strength of four restorative materials clinical dentistry: the replica technique. roughness on the in vitro biofilm formation
to enamel and dentin. J Prosthet Dent Microsc Res Tech 2020;83:1118–1123. of Streptococcus mutans biofilm. Am
2004;92:245–249. 50. van den Breemer CRG, Özcan M, J Dent 2020;33:59–63.
40. Magne P, Spreafico RC. Deep margin Cune MS, van der Giezen R, Kerdijk W, 61. Svanberg M, Mjör IA, Ørstavik D. Mutans
elevation: a paradigm shift. Am J Esthet Gresnigt MMM. Effect of immediate dentine streptococci in plaque from margins of
Dent 2012;2:86–96. sealing on the fracture strength of lithium amalgam, composite, and glass-ionomer
41. Dablanca-Blanco AB, Blanco-Carrión J, disilicate and multiphase resin composite restorations. J Dent Res 1990;69:861–864.
Martín-Biedma B, Varela-Patiño P, Bello- inlay restorations. J Mech Behav Biomed 62. Hansel C, Leyhausen G, Mai UE,
Castro A, Castelo-Baz P. Management of Mater 2017;72:102–109. Geurtsen W. Effects of various resin
large class II lesions in molars: how to 51. Borgia E, Baron R, Borgia JL. Quality and composite (co)monomers and extracts on
restore and when to perform surgical crown survival of direct light-activated composite two caries-associated micro-organisms in
lengthening? Restor Dent Endod 2017;42: resin restorations in posterior teeth: a 5- to vitro. J Dent Res 1998;77:60–67.
240–252. 20-year retrospective longitudinal study. 63. Kuper NK, van de Sande FH,
42. Peumans M, Venuti P, Politano G, Van J Prosthodont 2019;28:e195–e203. Opdam NJM, et al. Restoration materials
Meerbeek B. Effective protocol for daily 52. Ferracane JL. Models of caries and secondary caries using an in vitro
high-quality direct posterior composite formation around dental composite biofilm model. J Dent Res 2015;94:62–68.
restorations. The interdental anatomy of the restorations. J Dent Res 2017;96:364–371. 64. Serra-Pastor B, Bustamante-
Class-2 composite restoration. J Adhes 53. Kim RJ, Kim YJ, Choi NS, Lee IB. Hernández N, Fons-Font A, Fernanda
Dent 2021;23:21–34. Polymerization shrinkage, modulus, and Solá-Ruíz M, Revilla-León M, Agustín-
43. van den Breemer CR, Özcan M, shrinkage stress related to tooth-restoration Panadero R. Periodontal behavior and
Pols MR, Postema AR, Cune MS, interfacial debonding in bulk-fill composites. patient satisfaction of anterior teeth restored
Gresnigt MMM. Adhesion of resin cement J Dent 2015;43:430–439. with single zirconia crowns using a

The International Journal of Esthetic Dentistry | Volume 18 | Number 2 | Summer 2023 | 159
CLINICAL RESEARCH

biologically oriented preparation technique: 66. Hickel R, Manhart J. Longevity of 69. Borgia E, Baron R, Borgia JL. Quality
a 6-year prospective clinical study. J Clin restorations in posterior teeth and reasons and survival of direct light-activated
Med 2021;10: 3482. doi:10.3390/ for failure. J Adhes Dent 2001;3:45–64. composite resin restorations in posterior
jcm10163482. 67. Donovan T, Simonsen RJ, Guertin G, teeth: a 5- to 20-year retrospective
65. Agustín-Panadero R, Serra-Pastor B, Tucker RV. Retrospective clinical evaluation longitudinal study. J Prosthodont
Loi I, Suárez MJ, Pelaez J, Solá-Ruíz F. of 1,314 cast gold restorations in service 2019;28:e195–e203..
Clinical behavior of posterior fixed partial from 1 to 52 years. J Esthet Restor Dent
dentures with a biologically oriented 2004;16:194–204.
preparation technique: a 5-year randomized 68. Henry DB. A clinical presentation of the
controlled clinical trial. J Prosthet Dent direct gold/composite sandwich restoration.
2021;125:870–876. Oper Dent 2022;47:123–130.

160 | The International Journal of Esthetic Dentistry | Volume 18 | Number 2 | Summer 2023