Case Report

Deep Margin Elevation With Resin-modified Glass Ionomer in Posterior Adhesive Indirect Restorations Based on Biomimetic Principles: A Case Report

Please cite this article as follows: Farhadi E, Ranjbar Omrani, L, Estedlal T, Ahmadi E.Deep margin elevation with resin-modified glass ionomer in posterior adhesive indirect restorations based on biomimetic principles: a case report. Avicenna J Dent Res. 2022; 14(4):190- 193. doi:10.34172/ajdr.2022.532

Introduction

Resorting the crown of endodontically treated teeth (ETT) is challenging. ETT are much more likely to fracture than vital teeth. A cusp coverage restoration is recommended, especially when the defect is extensive (1,2). Partial coverage crowns similar to ceramic onlays can be more conservative than full-coverage crowns for ETT (3,4).

Deep defects in teeth are associated with several clinical challenges, including difficulties in accessing, isolating, and controlling marginal adaptation and emergence profile. Two treatment options are used to manage these defects: crown lengthening (CL) surgery and deep margin elevation (DME). The CL procedure is limited when roots are short and bone removal leads to an undesirable crown/root ratio or exposure to furcation (5). Coronal relocation of subgingival margins, called DME, results in a more coronal margin by bonding several layers of direct resin composite to the deep margins (5,6). We can also use resin-modified glass ionomer (RMGI) in the DME procedure, which is biocompatible and much less sensitive to the technique and releases fluoride (7-9).

Biomimetic dentistry focuses on replicating natural tooth structures utilizing artificial materials which are called biomimetic materials. These attempts have been made to restore tooth structure by a hard tissue bond and to achieve its full function that unifies the tooth and its restoration and distributes the stresses throughout the tooth with near-normal functional, biological, and esthetic features (10,11).

Case Report

A 33-year-old male was presented to restore endodontically treated right lower molars one day after completing endodontic therapy (Figure 1A-C). Examination revealed deep margins in the distal wall of tooth N.46 and the mesial wall of tooth N.47. Based on clinical and radiographic findings and considering the opposing dentition with zirconia restorations, the fabrication of a direct restoration was ruled out. Following consultation with a periodontist, there were limitations to the CL procedure because when the roots are short, bone removal may lead to an undesirable crown/root ratio or exposure to furcation. The patient chose to save the teeth and restore them with indirect adhesive restoration, then teeth were isolated by a rubber dam (DermaDam, Ultradent Products).

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Figure 1.

(A) Clinical View of Tooth #47 Before Treatment. (B) Clinical View of Tooth #46 Before Treatment. (C) Periapical Radiograph of Teeth #46 and 47 Before Treatment

Figure 1.

(A) Clinical View of Tooth #47 Before Treatment. (B) Clinical View of Tooth #46 Before Treatment. (C) Periapical Radiograph of Teeth #46 and 47 Before Treatment

Using an RMGI restorative material (Fuji II LC, GC Tokyo, Japan), deep margins were relocated coronally to prevent the violation of biological width in those areas. After placing a Matrix band (Dentsply Sirona, USA) and wooden wedges which were stabilized with a resin material (Gingival barrier), gingival dentin was conditioned (Fuji Conditioner, GC America), and the mixed Fuji II LC material was syringed into the location as much as the capacity of gingival papilla for 2 mm. Then, a LED-based curing light (Valo, Ultradent Products, 1000 mW/cm², South Jordan, USA) was used to cure RMGI for 30 seconds. The RMGI layer was light-cured considering the buccal and lingual aspects for 30 seconds, after eliminating the matrix band (Figure 2). The cavity buildup was then completed with posterior resin composite (Filtek P60, 3M ESPE, Germany) and preparations were made for overlays (12). As observed in Figure 3, the preparation was done using butt joint preparation in the buccal and lingual walls on the enamel surface and slot preparation in the mesial and distal walls in both teeth (13).

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Figure 2.

Teeth # 46, 47 After DME Procedure. Note. DEM: Deep margin elevation

Figure 2.

Teeth # 46, 47 After DME Procedure. Note. DEM: Deep margin elevation

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Figure 3.

The Cavity Build up With Posterior Resin Composite and in Teeth #46 and 47. Note. The preparation was completed using butt joint preparation in buccal and lingual walls on the enamel surface and slot preparation in the mesial and distal walls in both teeth.

Figure 3.

The Cavity Build up With Posterior Resin Composite and in Teeth #46 and 47. Note. The preparation was completed using butt joint preparation in buccal and lingual walls on the enamel surface and slot preparation in the mesial and distal walls in both teeth.

Impressions were made using polyvinyl siloxanes (Express 3M ESPE) in a stock tray along with an impression using alginate (Alginoplast EM, Aroma Fine, Coe Alginate, and Jeltrate Plus) for the opposing arch. Lithium disilicate overlays (IPS e.max Press, Ivoclar Vivadent) were fabricated. Before cementation, restorations were examined for fitness and occlusion. A fine-grit football diamond bur (No. 8379 0014, Komet USA. Rock Hill, USA) was used to adjust restorations. We used diamond silicone polishing points (Dialite, Brasseler, USA) for the polishing step. The inner surface of overlays was etched and rinsed with 5% hydrofluoric acid (IPS Ceramic Etching Gel, Ivoclar Vivadent) for 20 seconds. Afterward, 37% phosphoric acid (BISCO Dental Products, USA) was rubbed on the etched area with a microbrush for 30 seconds and rinsed to eliminate porcelain residuum produced after hydrofluoric acid etching. An ultrasonic (Ultrasound Vita-Sonic II, Germany) was used to clean restorations for 5 minutes. After drying with air, a thin layer of silane (silane, Ultradent products) was applied for 1 minute, and a two-step etch and rinse dentin bonding system (Opti Bond Solo Plus, Kerr Corporation) was applied on the inner surface of the restorations and air-thinned. Next, a light protective barrier was placed on the restorations.

Enamel margins were etched for 15 seconds with the same 37% phosphoric acid, and more etchant was applied to build up material for 10 extra seconds and was rinsed for 15 seconds. High-volume suction was used to dry the surface. We applied two layers of a two-step etch and rinse dentin bonding system (OptiBond Solo Plus, Kerr Corporation) on the preparation surfaces of teeth and thinned them with a microbrush. After air-drying of the second layer and vaporization of its excessive solvent, it was polymerized for 20 seconds using a curing light.

For the cementation step, we used clear shade resin composite cement PANAVIA F.2 (PF2, Kuraray Noritake Dental). The extra resin cement was eliminated with the aid of a microbrush and dental floss. The polymerization of the resin cement was done for 20 seconds considering all aspects using a LED-based curing light. To polymerize any oxygen-inhibited layer, glycerin gel was applied to the margins, and they were light polymerized for 20 seconds again.

A minor occlusal adjustment was made, and the surface was polished using rubber points and fine grit diamond bur (Figure 4). A periapical radiograph was then taken to check marginal adaptation and removal of extra composite resin cement (Figure 5).

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Figure 4.

Lithium Disilicate Overlays After Cementation

Figure 4.

Lithium Disilicate Overlays After Cementation

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Figure 5.

Preapical Radiograph of Teeth #46 and 47 After Overlays Cementation

Figure 5.

Preapical Radiograph of Teeth #46 and 47 After Overlays Cementation

The restorations were followed with visual examination and radiographies six months later (Figure 6). The patient was asymptomatic without any evidence of fractures in restorations or teeth, carious lesions, or periodontal inflammation.

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Figure 6.

Periapical Radiograph Six Months After Cementation

Figure 6.

Periapical Radiograph Six Months After Cementation

Discussion

ETT may have deep subgingival margins which are technically challenging. For instance, placement of rubber dam, making an impression, and cementation are difficult, which affect the survival rate and health of periodontal tissue (14).

CL surgery has limitations in teeth with short root trunks, root proximity, and root concavities. DME is another method to relocate subgingival margins with RMGI or direct composite resin (15). The overall cumulative survival rate of 197 posterior teeth treated by DME technique followed by partial indirect restorations was reported to be 95.9% in12 years follow-up (16).

For the restoration described in the present study, RMGI restorative material was chosen for the DME procedure due to its ability to adhere chemically to the tooth structure, release of fluoride, biocompatibility to tissues, lower elastic modulus, resistance in streptococcus mutans, minor shrinkage stress, and hydrophilic nature which leads to unaffected microtensile bond strength when it has contact with water (17-19).

The build-up of the pulp chamber was performed (1) to follow the fundamental principle of IDS since it increases microtensile bond strength compared with delayed dentin sealing, (2) to block out the undercuts, (3) to achieve an accurate cavity geometry, and (4) to produce an optimal restoration material thickness (12).

Author Contributions

Conceptualization: Elham Farhadi.

Data curation: Elham Farhadi.

Formal Analysis: Elham Farhadi.

Funding acquisition: Elham Farhadi.

Investigation: Elham Farhadi.

Methodology: Elham Ahmadi.

Project administration: Elham Ahmadi.

Resources: Ladan Ranjbar Omrani.

Software: Elham Farhadi.

Supervision: Ladan Ranjbar Omrani.

Validation: Elham Ahmadi.

Visualization: Elham Farhadi.

Writing – original draft: Elham Farhadi.

Writing – review & editing: Taraneh Estedlal.

Conflict of Interest Disclosures

The authors declare that they have no conflict of interests.

Ethical Statement

Informed consent was obtained from the patient for the publication of this report.

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