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Clinical protocols

Deep Margin Elevation: A Biomimetic Protocol for Subgingival Margins

By Biomimetic Dentistry Club Editorial TeamPublished 7 min read

Summary

Deep margin elevation (DME), also called cervical margin relocation or proximal box elevation, is the placement of a composite layer at a deep, often subgingival, proximal margin to move the margin coronally. It enables rubber-dam isolation, accurate impressions and adhesive luting of an indirect restoration without surgical crown lengthening in selected cases.

  • Described by Dietschi and Spreafico (1998) and popularised as DME by Magne and Spreafico (2012).
  • Success depends on a perfectly adapted matrix and a well-sealed, overhang-free composite margin.
  • The relocated margin must not encroach on the supracrestal tissue attachment; otherwise surgical options are needed.
  • Dentin is sealed before the margin is elevated, combining DME with IDS.

Rationale

Deep proximal margins complicate every step of an indirect bonded restoration: isolation, impression-taking, cementation and removal of excess cement. Relocating the margin coronally with a direct composite simplifies these steps and allows the indirect restoration to finish on the composite rather than deep on the root surface.

Case selection

  • The margin can be isolated with a rubber dam and a matrix band that seals below the deepest point.
  • The biological requirements of the periodontium (supracrestal tissue attachment) can be respected; if not, crown lengthening should be considered.
  • The tooth is restorable and periodontally sound.

Common pitfalls

  • A matrix that does not seal apically, leading to composite overhangs or voids at the deepest point of the margin.
  • Elevating too far coronally, which leaves little room for the indirect restoration and moves the cement line into a less favourable position.
  • Contamination of the proximal box by blood or crevicular fluid during bonding; if isolation cannot be secured, DME is not the right approach.
  • Skipping radiographic verification, so that a gap or overhang at the elevated margin goes undetected.

Step-by-step protocol

  1. Isolate with a rubber dam; remove old restorations and caries.
  2. Place a matrix band that seals the deep margin; a curved or cut-down sectional or circumferential band often adapts better than a standard band.
  3. Verify the seal of the matrix at the margin; wedge as needed without deforming the band.
  4. Apply the adhesive protocol to the proximal box and seal the dentin (IDS).
  5. Place composite in small increments to elevate the margin, typically to a level that can be isolated and scanned predictably.
  6. Remove the matrix and check the margin for overhangs or gaps; a bitewing radiograph is recommended.
  7. Finish the elevated margin and complete the preparation for the indirect restoration.

Evidence and limitations

Laboratory studies and clinical reports support DME as a viable alternative to surgical crown lengthening in selected cases, provided the margin is well adapted and periodontal health is maintained. Reviews highlight that long-term clinical data are still limited and that marginal adaptation and radiographic verification are critical.

Frequently asked questions

Does deep margin elevation violate the biological width?

It should not. DME is only appropriate when the relocated margin respects the supracrestal tissue attachment. When the defect extends too far apically, surgical crown lengthening or other approaches should be considered.

References

  1. Dietschi D, Spreafico R. Current clinical concepts for adhesive cementation of tooth-colored posterior restorations. Pract Periodontics Aesthet Dent. 1998;10(1):47-54. Find on PubMed (opens in a new tab)
  2. Magne P, Spreafico RC. Deep margin elevation: a paradigm shift. Am J Esthet Dent. 2012;2(2):86-96. Find on PubMed (opens in a new tab)
  3. Juloski J, Köken S, Ferrari M. Cervical margin relocation in indirect adhesive restorations: a literature review. J Prosthodont Res. 2018;62(3):273-280. Find on PubMed (opens in a new tab)
  4. Frese C, Wolff D, Staehle HJ. Proximal box elevation with resin composite and the dogma of biological width: clinical R2-technique and critical review. Oper Dent. 2014;39(1):22-31. Find on PubMed (opens in a new tab)
  5. Magne P. Immediate dentin sealing: a fundamental procedure for indirect bonded restorations. J Esthet Restor Dent. 2005;17(3):144-154. Find on PubMed (opens in a new tab)

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