Received: 20 June 2024
| Revised: 23 August 2024
| Accepted: 6 September 2024
DOI: 10.1002/ccr3.9453
CASE REPORT
Deep margin elevation with one-year follow-up: A case
report
Mohammad Aljanakh
Department of Restorative Dentistry,
College of Dentistry, University of Ha'il, Key Clinical Message
Ha'il, Saudi Arabia Deep margin elevation (DME) is a conservative treatment of a tooth with exten-
sive subgingival caries. It is an alternative approach to more invasive restorative
Correspondence
Mohammad Aljanakh, Department procedures. The DME enables successful tooth isolation to do root canal treat-
of Restorative Dentistry, College of ments and enables performing indirect restorations, improving dental function
Dentistry, University of Ha'il, Ha'il,
Saudi Arabia.
and patient comfort without complications.
Email: [Link]@[Link]
KEYWORDS
case report, cervical margin relocation, deep margin elevation, dental caries, proximal box
elevation, subgingival margins
1 | I N T RO DU CT ION of the tooth.6 The technique facilitates better restoration
isolation and simplifies subsequent endodontic and prost-
Treatment of deep subgingival caries presents a significant hodontic procedures, preserving tooth structure and peri-
clinical challenge, often requiring an extraction followed odontal integrity. Recent publications have highlighted
by implant placement or other traditional prosthodontic the efficacy of DME, in posterior molars, reinforcing its
to replace the missing tooth.1 While traditional treatments utility and durability in complex dental restorations.7,8
such as orthodontic extrusion and crown lengthening pro- This case report demonstrates how DME helped a pa-
cedures aim to preserve tooth structure can negatively im- tient with extensive subgingival caries and asymptomatic
pact gingival health and esthetics.2 Additionally, implant irreversible pulpitis. It provides a detailed, evidence-based
placement is a good alternative for poor prognosis tooth clinical restorative treatment of a case with one-year fol-
and is highly predictable but requires invasive surgery, low-up. This case demonstrates the practical benefits
time, and higher cost on the patient.3,4 of DME as an alternative to more invasive traditional
Tooth extraction can often be avoided by performing methods.
deep margin elevation (DME), the DME technique has
been introduced as a conservative and innovative solu-
tion to address restorative challenges with minimal inva- 2 | C ASE PRESENTATION
siveness and optimal long-term outcomes.5 Dietschi and
Spreafico introduced DME in 1998, as the name indicates, A 57-year-old female patient presented to our private
it is the elevation the margins of deep caries lesions that dental clinic seeking a second opinion regarding the re-
were traditionally indicated for extraction by bonding a storability of her mandibular right first molar (tooth
dental resin composite base to the deep subgingival margin #46). She was in good general health, with no significant
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited and is not used for commercial purposes.
© 2024 The Author(s). Clinical Case Reports published by John Wiley & Sons Ltd.
Clin Case Rep. 2024;12:e9453. [Link]/journal/ccr3 | 1 of 5
[Link]
2 of 5 | ALJANAKH
medical history, medications, or allergies. Her primary 2.3 | Treatment procedure
complaint was discomfort due to food impaction between
the maxillary first and second molars, but there was no The treatment began after the patient gave her consent.
associated pain. Her dental history was notable only for In the first appointment, inferior alveolar nerve block an-
previous restorative treatments and extractions without esthesia was administered. Under rubber dam isolation,
complications. existing caries were removed with a slow-speed round
bur. A Tofflemire matrix was modified and then adapted
around the tooth using wooden wedges and Teflon tape
2.1 | Clinical findings (Figure 2). Bitewing radiographs confirmed the apical ex-
tent of the matrix band below the tooth structure apically
An extraoral examination revealed no abnormalities. The (Figure 1B).
intraoral examination revealed that #46 had no mobility. The tooth was etched with 37% phosphoric acid and
Periodontal probing depths were 2–3 mm with bleeding then thoroughly rinsed. Next, a coating of a Scotchbond
on probing. The pulp vitality test (cold) was normal, while Universal adhesive system (3 M ESPE) was applied,
the caries was extending to the pulp tissue, suggesting which was then light cured. The process of DME involved
asymptomatic irreversible pulpitis on #46. Bitewing X- first placing a thin layer of Tetric EvoFlow®Bulk Fill
rays of tooth #46 showed a large distal subgingival carious (Ivoclar Vivadent AG, Schaan, Liechtenstein), followed
lesion (Figure 1A). by a thicker layer of Tetric EvoCeram bulk fill composite
(Ivoclar Vivadent, Schaan, Liechtenstein). This layering
used the snowplow method, previously described by Frese
2.2 | Treatment plan et al.,9 (Figure 1C).
In the subsequent appointment, local anesthesia was
For tooth #46, the treatment options presented were as fol- administered. The tooth was isolated under a rubber dam.
lows: first, extraction and replacement with either a dental An endodontic access cavity was prepared. The canal ori-
implant, a long-span fixed partial denture, or a remov- fices were located and initially negotiated with 8–10 K files.
able prosthesis; second, periodontal surgery for clinical The working length was estimated with an electronic apex
crown lengthening or orthodontic extrusion, followed by locator and confirmed radiographically. The root canals
restoration of the tooth; third, DME and subsequent res- were then instrumented, and a 5.25% sodium hypochlorite
toration. After a comprehensive discussion regarding the irrigation was used and subsequently obturated using AH
diagnostic findings, treatment alternatives, potential risks Plus root canal sealer with corresponding gutta percha. The
and benefits, and associated costs, the patient elected to remaining gutta percha in the pulp chamber was removed
proceed with the DME option. This approach necessitated with a slow-speed round bur to prepare for the core buildup.
endodontic treatment, core build-up, and a full-coverage A dual- cure core buildup composite (MultiCore Flow,
indirect restoration for tooth #46. Ivoclar) was used for access cavity core buildup.
F I G U R E 1 (A) Preoperative X-ray showing deep distal caries. (B) Verification of matrix adaptation using a bitewing X-ray. (C) Deep
margin elevation performed in two bulk-fill layers using the snowplow technique.
ALJANAKH | 3 of 5
In the next appointment, tooth preparation for a full- 3 | DISC USSION
coverage zirconia crown and taking a final impression
using polyvinyl siloxane impression material were per- In this case report the use of DME in the treatment
formed (Figure 3A). A provisional crown was fabricated of extensive distal subgingival caries in a mandibular
chairside and cemented with temporary cement. right first molar was presented. The DME approach of-
In the final visit, the crown fit, and the proximal con- fers several advantages over other tooth replacement
tact and occlusion were verified, and then the tooth was methods, such as dental implants, partial fixed den-
isolated with a rubber dam, etched, and a universal adhe- tures, or removable dentures or the traditional meth-
sive (Scotchbond Universal, 3 M) was applied to the tooth. ods of crown lengthening.4,7 These advantages include
The monolithic zirconia crown was then cemented using cost-effectiveness, simplicity and short treatment time,
dual-cure resin cement (RelyX Unicem, 3 M) (Figure 3B). while preserving the natural structure and function of
A bitewing radiograph was used to verify the seating of the the teeth. However, DME can be unpredictable, espe-
crown (Figure 3C). cially when “biological width” is violated, such as in
young patients with higher interdental bone. Therefore,
clinicians must assess each case individually to decide
2.4 | Follow up whether DME can be performed, or the alternative treat-
ment options can be considered.
Clinical and radiological examinations and oral hygiene The clinical findings in this case report suggest that
reinforcement were carried out during six- month and DME can be a viable restorative approach even when
one-year follow-up visits. The patient was asymptomatic, margins extend closer than the traditionally recom-
and the clinical and radiographic examinations revealed mended 3.0 mm biological width to the alveolar bone
no dental caries, periodontal inflammation, or periradicu- crest. While consensus guidelines have advised main-
lar inflammation (Figure 4A,B). The patient was satisfied taining at least 3.0 mm of supracrestal tissue attachment
with the treatment outcome, indicating better function (STA) to avoid inflammation and attachment loss.10
and no food accumulation. More recent evidence indicates this recommendation
may be overly conservative, several studies have noted
substantial variations in junctional epithelium dimen-
sions, ranging from 1.0–9.0 mm, calling into question
the validity of a universal 3.0 mm as a minimum re-
quired width from tooth margin to the alveolar bone.11,12
Ferrari et al.,13 proposed that DME margins could be
safely placed as close as 2.04 mm from bone when com-
bined with strict oral hygiene compliance. Furthermore,
literature found that DME to be well-tolerated clini-
cally with proper bonding and isolation.9,14,15,16 and this
F I G U R E 2 A modified Tofflemire matrix and holder assembly adapted “biologic width” appeared healthy and causes
showing distal apical extension. minimal periodontal inflammation.11 Therefore, the
F I G U R E 3 (A) Tooth preparation for indirect restoration. (B) Indirect monolithic zirconia crown after cementation. (C) Bitewing X-ray
showing good proximal fit of the margins.
4 of 5 | ALJANAKH
F I G U R E 4 (A) Tooth preparation
for indirect restoration. (B) Indirect
monolithic zirconia crown after
cementation.
successful outcome with minimal inflammation seen in despite extensive proximal caries, probably because
this case aligns with the growing body of evidence sug- physiological recession in this case helped maintain ac-
gesting slightly reduced “biological width” dimensions cepted biological width. Younger patients with higher
may be acceptable for DME restorations when oral hy- interdental bone levels may be at greater risk for bio-
giene is controlled. logical width violations, which could result in periodon-
A modified Tofflemire matrix band, packed with tal inflammation and attachment loss. Future studies
Teflon tape and wooden wedges, was used in this case re- should systematically evaluate outcomes based on fac-
port to facilitate the apical extension and adaptation of tors such as patient age, subgingival extension, and oral
the matrix.5 Other matrix systems and techniques that hygiene status to develop evidence-based guidelines for
have been also reported for DME. For instance, an ap- case selection.
proaches like sectional matrices with Teflon tape apically
was reported.9 Others reported the “M-i-M technique”
that combines a circular matrix with an internal sectional 4 | CONC LUSION
matrix.5 As a general rule, effective isolation is empha-
sized as critical for proper adhesion and avoidance of This case report presents a successful DME for the treat-
contamination in the gingival fluid environment.5 ment of a challenging case of extensive subgingival proxi-
In this case report, a universal adhesive system was used mal caries of the mandibular first molar. This case report
because of its versatility and effectiveness in both total etch demonstrates that this conservative clinical strategy is
and selective enamel etch modes.16,17 The snowplow ap- beneficial and consistent with contemporary evidence-
proach was used to apply the composite restoration, which based dental practice and patient selection. Clinical lon-
entailed blending a light-cure flowable composite with a gitudinal studies should evaluate long-term outcomes and
more viscous composite resin.9 This method was designed optimize DME selection criteria to improve predictability
to increase the restoration's marginal seal and mechanical and clinical success.
qualities, as both flowable and viscous bulk-fill composites
have demonstrated appropriate microtensile bond strength AUTHOR CONTRIBUTIONS
and improved performance on enamel surfaces.18,19 Mohammad Aljanakh: Conceptualization; data cura-
Despite promising short-term results, the long-term tion; formal analysis; software; supervision; writing – orig-
durability and predictability of DME restorations are inal draft; writing – review and editing.
unclear. Clinical case reports and in vitro studies pro-
vide the most evidence.20 Longer-term prospective clini- ACKNOWLEDGMENTS
cal studies are needed to evaluate the longevity and risks The author has nothing to report.
of this technique, particularly how different restorative
materials respond to normal functional forces and the FUNDING INFORMATION
stresses of the oral environment and to determine how No funding was received for this paper.
DME affects periodontal health to enable dentists to
choose the technique with the best evidence-based re- CONFLICT OF INTEREST STATEMENT
storative materials. The author declares that there are no conflicts of interest
Finding criteria to select cases is important and re- regarding this paper's content, including dental materials,
quires more research. DME in this case was successful tools, and equipment.
ALJANAKH | 5 of 5
R2-technique and critical review. Oper Dent. 2014;39(1):22-31.
DATA AVAILABILITY STATEMENT doi:10.2341/13-052-T
The data used in this paper are available from the author 10. Padbury A Jr, Eber R, Wang HL. Interactions between the
upon reasonable request. gingiva and the margin of restorations. J Clin Periodontol.
2003;30(5):379-385.
ETHICS STATE MENT 11. Sarfati A, Tirlet G. Deep margin elevation versus crown
This case report was carried out in compliance with the lengthening: biologic width revisited. Int J Esthet Dent.
principles stated in the Declaration of Helsinki. 2018;13(3):334-356.
12. Schmidt JC, Sahrmann P, Weiger R, Schmidlin PR, Walter
C. Biologic width dimensions—a systematic review. J Clin
CONSENT Periodontol. 2013;40(5):493-504. doi:10.1111/jcpe.12078
The patient provided written informed consent for the 13. Ferrari M, Koken S, Grandini S, Ferrari Cagidiaco E, Joda T,
dental treatment procedure and the publication of this Discepoli N. Influence of cervical margin relocation (CMR)
case report, including any accompanying images, in ac- on periodontal health: 12-month results of a controlled trial. J
cordance with the journal's patient consent policy. Dent. 2018;69:70-76. doi:10.1016/[Link].2017.10.008
14. Bertoldi C, Monari E, Cortellini P, et al. Clinical and histolog-
ical reaction of periodontal tissues to subgingival resin com-
ORCID
posite restorations. Clin Oral Investig. 2020;24(2):1001-1011.
Mohammad Aljanakh [Link]
doi:10.1007/s00784-019-02998-7
org/0000-0002-4573-1224 15. Jepsen S, Caton JG, Albandar JM, et al. Periodontal manifes-
tations of systemic diseases and developmental and acquired
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