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Contents lists available at ScienceDirect

Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Review

Cervical margin relocation in indirect adhesive restorations: A

literature review
Jelena Juloskia,b,* , Serhat Kökena , Marco Ferraria,c
a
Department of Medical Biotechnologies, University of Siena, Siena, Italy
b
Clinic for Pediatric and Preventive Dentistry, University of Belgrade, Belgrade, Serbia
c
Department of Restorative Dentistry, School of Dentistry, University of Leeds, Leeds, UK

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: The aim of this review was to summarize the existing scientific literature investigating on
Received 29 July 2017 cervical margin relocation technique (CMR) performed prior to the adhesive cementation of the indirect
Received in revised form 29 September 2017 restorations.
Accepted 29 September 2017
Study selection: An electronic search with no date restriction was conducted in the MEDLINE database,
Available online xxx
accessed through PubMed. The following main keywords were used: “cervical margin relocation”, “coronal
margin relocation”, “deep margin elevation” and “proximal box elevation”.
Keywords:
Results: Seven in vitro studies and 5 clinical reports investigating on CMR are taken into consideration for
Cervical margin relocation
Proximal box elevation
the present review. The most frequently investigated parameter in almost all of the in vitro studies was
Deep margin elevation the marginal adaptation of the indirect restorations. One study additionally assessed the influence of
Indirect adhesive restorations CMR on the fracture behavior of the restored teeth and one study assessed the bond strength of the
Review indirect composite restoration to the proximal box floor. Clinical reports provided documentation with a
detailed description of the treatment protocol. In the current literature no randomized controlled clinical
trials or prospective or retrospective clinical studies on CMR technique could be found.
Conclusions: On the basis of the reviewed literature, it can be concluded that currently there is no strong
scientific evidence that could either support or discourage the use of CMR technique prior to restoration
of deep subgingival defects with indirect adhesive restorations. Randomized controlled clinical trials are
necessary to provide the reliable evidence on the influence of CMR technique on the clinical performance,
especially on the longevity of the restorations and the periodontal health.
© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction between the restorative margins and the alveolar crest that is
considered necessary in order to avoid detrimental effects on
Restoring large posterior defects with proximal caries extend- neighboring soft and hard periodontal tissues [4]. If the principle of
ing below the cemento-enamel junction (CEJ) and cavity margins biologic width is not respected, it is suggested to obtain the
located beneath the gingival tissues represents a very common necessary space in one of two ways: surgically, by surgical crown
clinical situation. Due to advances in adhesive technology, lengthening [5] or orthodontically, by tooth extrusion [6].
development of modern materials and increasing aesthetic The technical-operative problems start with difficulties in tooth
requests, a treatment plan in such cases often includes indirect preparation in subgingival areas and are followed with a series of
adhesive restoration [1,2]. Unfortunately, when restoring cavities challenges in the impression taking, the adhesive cementation of
with deep cervical margins two major clinical problems may occur: the restoration and the successive phases of finishing and polishing
problems of biological nature and technical-operative problems of the margins [7]. Most of the above mentioned issues are related
[3]. to inferior insight and access to the deep parts of the cavity and
The biological problems refer to the possible violation of the impossible or inadequate isolation of the operating field with a
“biological width”, a recommended distance of 3 mm or more rubber dam, which leads to inappropriate moisture control and
blood and/or saliva contamination throughout the clinical
procedures [8].
To make the clinical procedures simpler and less fault-prone,
* Corresponding author at: Department of Medical Biotechnologies, Policlinico Le
Dietschi and Spreafico in 1998 introduced a technique named
Scotte, Viale Bracci 16, Siena 53100, Italy.
E-mail address: juloski@unisi.it (J. Juloski). “cervical margin relocation” (CMR) [9]. In 2012 Magne and Spreafico

https://doi.org/10.1016/j.jpor.2017.09.005
1883-1958/ © 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

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referred to the same technique as “deep margin elevation” (DME) The search and the selection process carried out by two review
[10]. Similar names, such as “coronal margin relocation” and authors independently finished on 1st June 2017. After the
“proximal box elevation”, could also be heard among the practi- screening of the titles and the abstracts, full texts of all reviewed
tioners and found in the literature. This technique proposes articles were obtained and carefully read. Upon the discussion
application of composite resin in the deepest parts of the proximal between the authors, on the basis of the reported inclusion and
areas in order to reposition the cervical margin supragingivally, exclusion criteria, 7 in vitro studies, 1 review article with a case
which is supposed to facilitate the isolation and improve impression report and 4 articles describing the CMR technique were selected
taking and adhesive cementation of indirect restorations [9,10]. The for the present literature review.
CMR technique could be considered, to a certain extent, as a non-
invasive alternative to a surgical crown lengthening. 3. Results
The problem of extensive subgingival defects that still remains,
regardless of the technique applied, is limited or no enamel present The results of the reviewed studies were categorized and
at deep cervical margins, leaving only dentin and cementum as the presented in two main parts: (1) review of in vitro studies and (2)
main substrates for adhesion. Adhesive bonding to the etched review of clinical reports.
enamel is proved to be efficient and stable [11]. Adhesion to dentin,
on the other hand, depends on numerous factors related to the 3.1. Review of in vitro studies
substrate morphology [12], on the type of the adhesive [13] and on
the sensitive application technique [14]. Therefore, adhesive In the current scientific literature 7 in vitro studies investigating
bonding to deep cervical dentin and maintaining the margins of on CMR are taken into consideration for the present review
the adhesive restoration sealed throughout the time could not be [15–21]. The most frequently investigated parameter in almost all
considered entirely predictable and safe. of the studies was the marginal adaptation of the indirect
Whether the CMR technique is the most optimal treatment restorations [15–19,21]. Only one study additionally assessed the
option for the restoration of deep cavities reaching below CEJ, how influence of CMR on the fracture behavior of the restored teeth [18]
the proposed advantages and possible disadvantages could affect and one study assessed the bond strength of the indirect composite
the clinical performance of the indirect restorations and which are restoration to the proximal box floor [20]. The overview of the
the most appropriate materials and techniques that should be main characteristics, the materials employed and the designs of
applied in such situations are the topics extensively discussed the reviewed studies are reported in Table 1.
among clinicians. Nevertheless, not much scientific support could
be found in the currently available literature. Therefore, the aim of 3.1.1. Marginal adaptation
this review was to summarize the existing scientific knowledge on All 6 studies that evaluated the influence of CMR on the
CMR technique performed prior to the adhesive cementation of the marginal quality of the adhesively luted restorations performed
indirect restorations. the analysis using the scanning electron microscopy (SEM),
observing the margins on gold-sputtered epoxy resin replicas of
2. Study selection the teeth at 50 [19] and 200 magnification [15–18,21]. The
marginal integrity was calculated in the same way, as the
2.1. Search strategy percentage of continuous margin in relation to the individual
assessable margin, following the well-established protocol consis-
For the identification of the studies to be included in this tent with previous studies [22]. The quality of the marginal
review, an electronic search with no date restriction was adaptation was assessed before and after thermo-mechanical
conducted in the MEDLINE database, accessed through PubMed. loading (TML) [15–19,21]. However, the adhesive interfaces that
The following main keywords were used: “cervical margin were observed and analyzed were not always the same in all of the
relocation”; “coronal margin relocation”; “deep margin elevation” studies.
and “proximal box elevation”. A further manual search was Most of the studies supported the fact that no differences
performed as well; checking for eligible papers in the bibliogra- existed in marginal quality of the restorations placed directly on
phies of the initially retrieved articles and exploring the websites dentin, following the conventional luting procedure, or on
of the relevant journals. composite restorations used for relocation of the cervical margin
[15,17–19,21]. One study recorded that, only after being subjected
2.2. Inclusion criteria to TML, conventional technique showed superior marginal
adaptation compared to CMR technique [16]. Moreover, in most
The present review sought only for articles where composite of the studies TML was found to significantly deteriorate the
resin materials were used as materials for relocation of the cervical integration at enamel and dentin margins [15–17] and at onlay/
margin. Only articles considering indirect adhesive restoration, as a luting composite interface [18]. But it was also recorded that TML
type of final restoration, were included. Because no randomized did not result in inferior marginal quality, regardless of the
controlled clinical trials (RCTs) existed in this field, descriptive materials tested [19,21].
studies that made reference to the CMR clinical procedure were With regard to the materials employed for CMR, one study
also included. The search was limited to the articles published in investigated on the performance of flowable and conventional
English language. restorative composite materials when used for CMR [19]. No
significant differences in the marginal integrity were found
2.3. Exclusion criteria between traditional or flowable composite, before or after TML,
for either ceramic or composite CAD/CAM crown [19]. The
Publications focusing on relocation of the cervical margin using potential use of self-adhesive resin cements as material for
glass ionomer cements were not included in the present review. CMR, although deviant from their original indication spectrum, has
Studies that used teeth without a restoration or teeth restored with been explored due to their easy clinical manipulation that could be
a direct composite restoration with subgingival cervical margin appealing for dental practitioners [15,16]. Based on the discourag-
were also excluded. Articles in any language other than English ing results obtained and significantly inferior quality of the
were left out. marginal adaptation to dentin, they were not recommended for

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this indication in clinical practice, although differences were groups where composite was layered in one or three increments,
noticeable among various self-adhesive cements [15,16]. after TML significant degradation of the interface was noticed and
Moreover, in order to evaluate whether polymerization statistically significant differences emerged among the groups
shrinkage of composite material used for CMR could affect the [15,16]. In particular, bonding directly to dentin without CMR was
quality of the margins, 3 investigations were performed applying found to be comparable to CMR composite layered in 3 increments
one or more layers of composite on the cervical margin of the but significantly better than CMR applied only in one layer [15]. In a
proximal boxes [15–17]. Two 1.5-mm increments of a fine hybrid subsequent study of the same group of authors [16], the results
composite (Tetric A2; Ivocalr Vivadent, Schaan, Liechtenstein) were slightly different. Conventional luting technique directly to
applied for CMR did not perform any better then did one 3-mm dentin performed significantly better even than dentin covered
increment, in terms of marginal adaptation of the final restoration with 3 layers of composite, which was also significantly better than
[17]. On the contrary, results of another two studies [15,16] showed CMR applied only in one layer. Therefore, the authors concluded
that marginal integration to dentin of a restorative composite that, although conventional luting procedure is considered as the
(Clearfil Majesty Posterior; Kuraray, Noritake Dental Inc., Tokyo, most effective over time, the CMR technique could be accepted a
Japan) is improved when composite is layered in three consecutive valid procedure and application of composite in more layers
1-mm increments than in one 3-mm increment for CMR. Although achieved better performance in terms of marginal quality to dentin
initially no difference existed among group without CMR and compared to a single layer application [15,16].

Table 1
Overview of the in vitro studies.

Author/ Groups (study design) CMR adhesive/composite material Number of Luting agent of final restoration Type of final indirect restoration
reference CMR
composite
layers
Marginal adaptation
Roggendorf 5 groups: (1) and (2) CMR 2 self-adhesive resin cements: (1) 1 layer Total-etch adhesive Syntac Primer, Laboratory made composite
et al. [15] with self-adhesive cements Maxcem Elite (Kerr), (2) G-Cem (3 mm); Syntac Adhesive, Heliobond MOD inlay Clearfil Majesty
(3) CMR in 1 layer; (4) CMR in (GC Corp.); (3) and (4) self-etch 3 layers (Ivoclar Vivadent) + resin cement Posterior (Kuraray)
3 layers; (5) without CMR. adhesive AdheSe (Ivoclar, (3  1 mm) Variolink II (Ivoclar Vivadent)
Vivadent) + Clearfil Majesty
Posterior (Kuraray)
Frankenberger 6 groups: (1), (2) and (3) CMR 3 self-adhesive resin cement: (1) 1 layer Total-etch adhesive Syntac Primer, CAD/CAM-fabricated MOD
et al. [16] with self-adhesive cements Maxcem Elite (Kerr), (2) G-Cem (3 mm); Syntac Adhesive, Heliobond inlay: leucite-reinfirced glass-
(4) CMR in 1 layer; (5) CMR in (GC Corp.), (3) RelyX Unicem (3M 2 layers (Ivoclar Vivadent) + resin cement ceramic IPS Empress CAD
3 layers; (6) without CMR. ESPE); (4) and (5) self-etch (2  1.5 mm) Variolink II (Ivoclar Vivadent) (Ivoclar Vivadent)
adhesive AdheSe (Ivoclar,
Vivadent) + Clearfil Majesty
Posterior (Kuraray)
Zaruba et al. 4 groups: (1) margin in Total-etch adhesive Syntac Primer, 1 layer Total-etch adhesive Syntac Primer, CAD/CAM-fabricated MOD-
[17] enamel; (2) margin in dentin, Syntac Adhesive, Heliobond (3 mm); Syntac Adhesive, Heliobond inlay: feldspatic ceramic
CMR in 1 layer; (3) margin in (Ivoclar Vivadent) + fine hybrid 2 layers (Ivoclar Vivadent) + fine hybrid (Vitablocs Mark II, Vita)
dentin, CMR in 2 layers; (4) composite Tetric A2 (Ivoclar (2  1.5 mm) composite Tetric A2 (Ivoclar
margin in dentin, without Vivadent) Vivadent)
CMR.
Spreafico et al. 4 groups: 2 groups based on (1) 3-step total-etch adhesive 2 layers Total-etch adhesive Optibond FL CAD/CAM-fabricated crowns:
[19] restorative material used for Optibond FL (Kerr) + Filtek Flow (2  1 mm) (Kerr) + RelyX Ultimate (3M ESPE) (1) resin composite with
CMR and 2 subgroups based Supreme XTE (3M ESPE); (2) 3- nanoceramic fillers (Lava
on material used for step total-etch adhesive Optibond Ultimate, 3M ESPE); (2) lithium
fabrication of the crowns. FL (Kerr) + Filtek Supreme XTE disilicate (IPS e.max CAD,
(3M ESPE) Ivoclar Vivadent)
Müller et al. 3 groups: based on material Scotchbond Universal Adhesive Not (1) Scotchbond Universal CAD/CAM-fabricated MOD-
[21] used for luting the inlays (3M ESPE) in total-etch specified Adhesive (3M ESPE) in total-etch inlay: resin composite with
mode + Filtek Supreme XTE (3M (layers of mode + RelyX Ultimate (3M ESPE); nanoceramic fillers (Lava
ESPE) 2 mm) (2) total etch adhesive Syntac Ultimate, 3M ESPE)
Primer, Syntac Adhesive,
Heliobond + Variolink II (Ivoclar
Vivadent); (3) self-adhesive resin
cement Panavia SA Cement
(Kuraray)

Marginal adaptation and fracture behaviour

Ilgenstein et al. 4 groups: 2 groups based on 3-step total-etch adhesive 2 layers Scotchbond Universal Adhesive CAD/CAM-fabricated MOD-
[18] presence or absence of CMR Optibond FL (Kerr) + Tetric (2  1 mm) (3M ESPE) in total-etch onlay: (1) feldspatic ceramic
and 2 subgroups based on EvoCeram (Ivoclar Vivadent) mode + RelyX Ultimate (3M ESPE) (Vitablocs Mark II, Vita): (2)
material used for fabrication resin composite with
of the onlays. nanoceramic fillers (Lava
Ultimate, 3M ESPE)

Microtensile bond strength

Da Silva 4 groups: 2 groups based on Total-etch adhesive system Adper 2 layers (1) total-etch adhesive system Indirect laboratory made
Gonçalves presence or absence of CMR Scotchbond 1 XT (3M (2  1 mm) Adper Scotchbond 1 XT (3M composite inlay (Gradia
et al. [20] and 2 groups based on resin ESPE) + Filtek Z250 (3M ESPE) ESPE) + Relyx AEC; (2) self- Indirect; GC Corp.)
cement used for luting the adhesive resin cement G-Cem (GC
inlays. Corp.)

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The influence of CMR on the marginal integrity of indirect located in dentin 1 mm below the CEJ were compared with those
restorations made of different materials was the issue investigated where cervical margins were relocated 1 mm above CEJ using a
and discussed in two studies [18,19]. In both studies the restorative composite (Filtek Z250; 3M ESPE, USA) applied in two
restorations were prepared by CAD/CAM technology. One study 1-mm thick increments. Further aim of this study was to compare
tested onlays milled of feldspathic ceramic (VITABLOCS Mark II, the bond strength of inlays luted with two different cements: resin
Vita Zahnfabrik, Bad Säckingen, Germany) and composite resin cement used with total-etch adhesive (RelyX ARC used in
blocks with nanoceramic fillers (LAVA Ultimate; 3M ESPE, St. Paul, combination with Adper Scotchbond 1XT; 3M ESPE) and self-
MN, USA) [18], while another study used the same composite adhesive resin cement (G-Cem; GC Corp., Tokyo, Japan).
blocks (LAVA Ultimate) to fabricate crowns and compared their The results showed that MTBS values increased when the
behavior to crowns made of lithium disilicate (IPS e.max, Ivoclar proximal cavity floor was elevated with a composite. However, this
Vivadent, Schaan, Liechtenstein) [19]. These two studies reported, difference in bond strength was statistically significant only when
to a certain extent, conflicting results. While Spreafico et al. [19] self-adhesive resin cement was used for the cementation of the
found no significant differences in marginal integrity between inlay. When resin cement with a total-etch adhesive was used for
margins with and without CMR for both types of crowns, before or luting there was no significant difference between the groups with
after TML, Ilgenstein et al. [18] revealed that composite inlays and without CMR. According to the authors, the main reason for
exhibited overall better marginal integrity compared to ceramic such a result could be the good interaction between the resin
inlays. In particular, at the tooth/composite interface after TML, composite used for CMR and the self-adhesive resin cement. When
composite inlays luted directly to dentin measured significantly two luting cements were compared within the same location of the
higher percentage of continuous margins than any other group. In cervical margin, no significant differences in bond strength were
addition, comparing only the groups with CMR at the onlay/luting recorded, regardless of their different mechanism of adhesion to
composite interface, before and after TML, a significant reduction dentin. However, one should also take into consideration that the
in marginal quality was detected in specimens restored with failures during MTBS testing happened at the different interfaces.
ceramic onlays, while degradation of the margin was not observed In both groups with CMR the most frequent mode of failure was
for teeth restored with composite onlays. It should be mentioned adhesive failure between dentin and composite used for CMR,
that the restorative material LAVA Ultimate CAD/CAM used for which supports the fact that good bonding is achieved between
fabrication of crowns [19], the manufacturer no longer indicates resin cement and CMR composite, as well as the fact that bonding
for crowns. The material continues to be indicated only for to cervical dentin still remains challenging and unpredictable [11].
restorations with an internal retentive design element (such as Also, noticeable difference in failure modes was reported in groups
inlays and onlays) and veneer restorations. This is to be considered without CMR. While 60% of specimens cemented with self-
when interpreting the results of the studies investigating on adhesive resin cement failed adhesively between dentin and resin
crowns made of this material. cement, the same percentage of specimens luted with a total-etch
The study by Müller et al. focused on the material for luting the adhesive and a resin cement showed mixed adhesive failures.
inlays, when bonded directly to dentin of deep proximal cavities
and when bonded to restorative composite material used for CMR 3.2. Review of clinical reports
[21]. No difference was observed in terms of marginal integrity for
luting the inlays directly to dentine or composite used for CMR. In the current literature no randomized controlled clinical trials
Also, no significant reduction of integrity was found after TML and or prospective or retrospective clinical studies on CMR technique
all investigated materials showed promising results for luting the could be found. One review article that specifically concentrated on
indirect restorations. Therefore, this study suggests that there is no this topic and that reported a clinical case was identified [23]. One
difference in bonding the inlay to dentine or composite used for article presented the principles of the technique [10]. In addition,
CMR. However, the critical interface between the dentin below CEJ several review articles on indirect adhesive restorations in
and CMR composite was the matter of interest of this study. posterior areas looked back also on the CMR technique
[3,24,25]. These articles provided clinical documentation with a
3.1.2. Fracture behavior detailed description of the treatment protocol. The protocols
The study by Ilgenstein et al. [18] additionally investigated the suggested and described in the above mentioned articles became
impact of CMR and material of CAD/CAM onlays on the fracture the matter of this part of the present review (Table 2).
behavior of endodontically treated molars. After TML the teeth
were subjected to load until failure in order to determine the 3.2.1. CMR material
resistance to fracture and the fracture pattern. The lowest mean With regard to the most appropriate adhesive system and
fracture value was recorded for group without CMR and feldspathic composite material employed for the supragingival relocation of
ceramic onlay and the highest mean value for group without CMR the cervical margin, various recommendations were found in the
and composite resin onlay. Between these two values there were current literature. Most of the reviewed articles consider a
the two groups that have undergone cervical margin relocation, traditional 3-step total-etch adhesive as the preferred adhesive
which both revealed similar fracture resistance regardless of the system [10,23,25], such as OptiBond FL (Primer and Adhesive, Kerr
material used for the onlay restoration. The only statistically Corp., Orange, CA, USA) [10] or Syntac (Primer, Adhesive and
significant difference in load to fracture was noticed between two Heliobond, Ivoclar Vivadent, Lichtenstein) [23]. In order to avoid
groups without CMR. Additionally, the study demonstrated that over-etching of dentin in the subgingival area where enamel is
ceramic restorations tend to have less severe fractures that do not usually very thin, if any is present, Rocca et al. suggest
involve tooth itself, whereas composite restorations transfer more simultaneous etching of thin interproximal enamel in this area
stress to tooth structure causing catastrophic fractures below the together with dentin only for 5–10 s, or, as an alternative, 2-step
bone level. self-etch adhesive systems can be used without performing
selective enamel etching [25].
3.1.3. Bond strength Furthermore, both flowable as well as traditional viscous
One study aimed to evaluate the influence of CMR on the restorative composites could be selected for CMR technique,
microtensile bond strength (MTBS) of composite inlays to the according to the mentioned studies. Specifically, in a case
proximal box floor [20]. The groups with proximal cervical margin presented by Kielbassa and Philipp, a base of flowable composite

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(Gaenial Universal Flo, GC Corp., Tokyo, Japan) was applied, margin should be relocated to at least 0.5 mm over the free gingival
followed by small portions of filled viscous composite resin margin [25], if more material is needed, a combination of flowable
(Gaenial, GC Corp.) [23]. On the other hand, flowable composite in and traditional restorative composite is proposed [24]. The light
1–1.5-mm thickness was proposed by Veneziani [3] and up to curing of the final composite increment should be protected by a
2 mm thickness of the flowable or traditional restorative compos- thick layer of glycerin gel [10,25], as to eliminate the superficial
ite, in 1 or 2 increments, was suggested by Magne and Spreafico oxygen inhibition layer, which can interfere with the setting of
[10]. Besides, it was also noted that, if microhybrid or nanohybrid some impression materials [26].
restoratives are to be used, they should be preheated, to facilitate
placement and minimize the risk of interlayer gaps [10]. Moreover, 3.2.2. Application technique
two articles specify that highly filled flowable composites (e.g, According to Veneziani, three different clinical situations can
Premise Flow; Kerr Corp., Orange, CA, USA) or bulk fill flowables (e. be identified, based on technical-operating and biological
g, SureFil SDR Flow; Dentsply Pty. Ltd., Victoria, Australia) are parameters [3]. Only in Grade 1, when rubber dam can be
highly recommended for CMR, due to its consistency and ease of correctly placed in the sulcus sufficiently to show the cervical
use [24,25]. Flowables should, however, not be used in thick layers, margin, the coronal relocation of the margin could be carried out.
and their thickness should be limited to 1–1.5 mm [24,25]. As the In the other two clinical situations, surgical exposition of the

Table 2
Overview of the clinical reports.

Author/ CMR CMR composite Thickness, Rubber Matrix and Finishing of Treatment Luting agent of Type of final Follow-up
reference adhesive material number of CMR dam wedge CMR prior to final restoration indirect period
composite isolation application composite bonding of restoration
layers final
restoration
Veneziani Not Flowable Flowable Yes Circumferential Not specified Not Not specified Composite Not
[3] specified composite composite 1 to stainless steel specified onlays applicable
1.5 mm thick matrix and
wooden wedge
Magne 3-step Flowable or 2 mm thickness Yes Modified curved Elimination Cleaning Not specified Indirect Two cases
and total-etch traditional of the CMR Tofflemire of excess with ceramic at 9 and
adhesive
Spreafico [10] restorative composite (1 or matrix, matrix with no.12 airborne- onlay 12 years
(eg, materials; 2 increments) height reduced to blade or a particle follow-up
OptiBond microhybrid or 2 to 3 mm; if sickle scaler abrasion
FL; Kerr) nanohybrid necessary matrix-
restoratives in-a-matrix
should be technique;
preheated wedging is
typically not
possible
Kielbassa 3-step Flowable Not reported No Circumferential Bucket- Application 3-step total-etch CAD-CAM- 3 months
and total-etchcomposite stainless steel shaped of a primer adhesive Syntac fabricated
Philipp adhesive (Gaenial matrix fixed in diamond (GC Corp.) Primer, Syntac ceramic inlay
[23] Syntac Universal Flo, Tofflemire burs, flexible Adhesive, (IPS Empress
Primer, GC Corp.), retainer and discs and Heliobond CAD, Ivoclar
Syntac followed by wooden wedge polishing (Ivoclar Vivadent)
Adhesive, small portions strips Vivadent) and
Heliobond of filled viscous Variolink II resin
(Ivoclar composite resin cement (Ivoclar
Vivadent) (Gaenial, GC Vivadent)
Corp.)
Dietschi Type of Highly filled The use of Yes Full stainless steel Not specified Not Highly filled CAD/CAM- Not
and adhesive flowable flowable up to or clear matrix specified light-curing fabricated applicable
system not composites are
Spreafico [24] 1 to 1.5 mm; if and a wedge restorative restorations
specified recommended more material is composite made of resin
(Premise Flow, needed a material (eg, composite
Kerr) or a bulk combination of microhybrid with
fill flowable (eg, flowable and Tetric, Ivoclar; or nanoceramic
SureFil SDR restorative a homogenous fillers (Lava
Flow) composite is nanohybrid Ultimate, 3M
recommended (Inspiro, ESPE)
EdelweissDR)
Rocca Total-etch Highly filled Limit to the Yes Curved matrix, Fine Sandblasting Light-curing In-lab Not
et al. or 2-step flowable or minimum (1 to full or sectional diamond restorative composite applicable
[25] self-etch hybrid 1.5 mm) needed and a wedge instruments material resin onlays
adhesive composite to bring the (wedge when to remove (Tetric Evo
system preparation possible) the excess Ceram,
supragingivally Ivoclar
(at least 0.5 mm Vivadent)
over the free
gingival margin)

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margin (Grade 2) or surgical lengthening of the clinical crown 4. Discussion

(Grade 3) is necessary in order to allow for correct isolation of the
operating field. In accordance to these recommendations, the The idea to overcome the difficulties associated with the
CMR technique is indeed contraindicated if the cervical prepara- placement of restorations in the areas difficult to access by
tion is not perfectly isolated with a rubber dam and a matrix applying a base that is open to the oral environment underneath,
[10,24,25]. Nevertheless, the case reported by Kielbassa and originates from the “open sandwich technique” in direct composite
Philipp showed a clinical protocol where rubber dam was not Class II restorations. Initially, glass-ionomer cements (GICs) were
used for relocation of the cervical margin [23]. The isolation with proposed as a base material [27] and later, with advancements in
rubber dam did not prevent bleeding and therefore it was dental material technology, resin-modified GICs [28], polyacid-
removed and the isolation was done using cotton rolls, dry-angles modified resin composites [29] and flowable composites [30] were
and saliva ejectors under utmost attention to prevent contami- investigated. Frese et al. [31] described the restoration of
nation [23]. extensively damaged teeth in two clinical steps and called it the
The use of either circumferential or sectional matrix, either “two-step R2-technique”. In the first step layers of flowable and
stainless steel or clear matrix is strongly advocated [3,10,23–25]. viscous composites were applied to relocate the gingival margin
Specifically, curved matrices are recommended, as the curvature supragingivally and in the second step a direct composite
allows convergence, adequate emergence profile and a tight restoration was placed [31]. Similarly, CMR technique was
subgingival fit [10,25]. Moreover, reducing the height of the matrix proposed as an analog approach to be applied underneath the
to 2–3 mm is suggested, so it is slightly higher than the height of indirect adhesive restorations and for that purpose only composite
the CMR and in that way the matrix could slide subgingivally and resin materials were indicated [9].
seal the margin more efficiently [10]. In addition, in cases of The in vitro investigations analyzed in this review used
extremely deep and localized subgingival cavities, the final option composite materials of various manufacturers, chemical compo-
could be the matrix-in-a-matrix technique [10]. sitions and viscosities (Table 1). Based on the reported findings, the
Regarding the wedging, although it was reported that wedging overall conclusion could be that the marginal integrity of the
is typically not possible [10] or that it is not always possible [25], in indirect restorations was not significantly influenced by the
most of the clinical cases presented in the published articles, application of CMR. Also, the viscosity of the composite resin
matrix in combination with a wooden wedge was anyway applied was not found to be crucial for the quality of the margins, whereas
[3,23,24]. the application of composite in several thinner layers could be
considered advisable. Regarding the influence of the restorative
3.2.3. Treatment of CMR prior to bonding of final restoration material used for fabrication of final indirect restoration on the
In order to obtain well-defined margins, finishing and polishing integrity of the relocated cervical margins, no conclusive evidence
of the restorative material placed at the cervical margin are could be found.
required as the last step before impression taking. Elimination of Nevertheless, the quality of marginal adaptation, as observed
the excess composite material could be done using a scalpel or a under a microscope, does not necessarily have to correspond to the
sickle scaler [10]. Fine diamond rotary instruments are suggested quality of the marginal seal of the adhesively bonded composite
for removing the excess material, for finishing and polishing, as material. Inadequate sealing ability may cause leakage of oral fluids
well as for obtaining the optimal cavity design [23,25]. Besides, and microorganisms along the tooth/composite interface, which
finishing of the relocated cervical margins was also completed represents one of the major causes of failure of composite
using flexible discs of decreasing grit and polishing strips [23]. restorations [32]. Microleakage at the gingival margins of direct
However, the question remains how deeply subgingival interprox- Class II composite restorations [33,34], as well as of indirect
imal margins could be reached by any of the mentioned materials restorations, both ceramic [35] and composite [36], has been well
and instruments. documented. In addition, application of flowable composite on the
Before proceeding with the final impression, Magne and gingival margin as a liner in direct composite restorations did not
Spreafico advise a bitewing radiograph to evaluate the adaptation reduce microleakage or improve clinical performance of the
of the CMR composite resin in the subgingival area and to make restorations [37]. Based on the available evidence, it could be
sure that there are no gaps or overhangs [10]. assumed that applying a layer of composite underneath an indirect
After taking digital or analog impression and fabrication of the restoration would not prevent leakage. However, no study so far
final restoration, different protocols for treatment of the relocated assessed the leakage at the gingival margins that have been
margin were described. Most of the articles suggest cleaning the relocated above CEJ with a composite resin. This would certainly be
composite by sandblasting, using airborne-particle abrasion worth investigating in order to obtain more relevant information
[10,25]. In one case the CMR composite resin was primed (GC regarding the in vitro performance of the CMR.
Primer, GC Corp, Japan) prior to adhesive luting of the final It should also be noticed that in 6 laboratory studies
restoration, in order to achieve safe bonding, as reported by the investigating on the marginal integrity the interfaces that were
authors [23]. examined were not always the same. As a matter of fact, in some of
the studies it was not completely clearly described which of the
3.2.4. Follow-up margins were evaluated. Besides, the material adaptation to the
The clinical case of left second maxillary molar restored with enamel margins, judged in some of the studies, could not be
the CMR and CAD/CAM ceramic inlay presented by Kielbassa and considered essential for assessing the influence of the CMR
Philipp [23] was followed up for 3 months. Clinical appearance technique on the marginal adaptation of indirect restorations. In
showed no signs of inflamed papilla, probing did not reveal the upcoming research more attention should be given to the most
increased probing depth, no bleeding was observed on probing and critical margin, the one in dentin, below the CEJ. Different aspects
no discomfort was reported by the patient. related to the adhesion of the composite material used for CMR to
Long-term clinical view and corresponding radiographs of two dentin and to indirect restorations, as well as to the analysis of the
different cases, 9 and 12 years after treatment with CMR and fracture behavior, the expected fracture pattern and the stress
indirect ceramic restorations, are available in the article by Magne distribution could be the matter interest of future laboratory
and Spreafico [10]. research.

Please cite this article in press as: J. Juloski, et al., Cervical margin relocation in indirect adhesive restorations: A literature review, J Prosthodont
Res (2017), https://doi.org/10.1016/j.jpor.2017.09.005
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JPOR 436 No. of Pages 8

J. Juloski et al. / journal of prosthodontic research xxx (2017) xxx–xxx 7

Moreover, the recent meta-analysis indicates that the survival term clinical outcome of teeth restored with indirect adhesive
rate of ceramic inlays, onlays and overlays remains high (91%) restorations.
after 10 years of follow-up time, regardless of the ceramic
material, study design and study settings [2]. Another literature
5. Conclusions
review reported 94% average success for ceramic and composite
indirect restorations, concluding that the low failure rate prove
On the basis of the reviewed literature, it can be concluded that
them to be an excellent choice in treatment of both Class I and II
currently there is no strong scientific evidence that could either
lesions [1]. Nevertheless, the extent of the cavities below gingival
support or discourage the use of CMR technique prior to
margins was not included in any of the analysis and no distinction
restoration of deep subgingival defects with indirect adhesive
was made between cavities with proximal cervical margins in
restorations. Randomized controlled clinical trials are necessary to
enamel and those in dentin, which could considerably affect the
provide the reliable evidence on the influence of CMR technique on
clinical outcome. The main problem discovered by the present
the clinical performance, especially on the longevity of the
review is that strong evidence on the clinical performance of
restorations and the periodontal health.
teeth restored with CMR technique and an indirect adhesive
restoration still does not exist. Only several presentations of the
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Res (2017), https://doi.org/10.1016/j.jpor.2017.09.005
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Please cite this article in press as: J. Juloski, et al., Cervical margin relocation in indirect adhesive restorations: A literature review, J Prosthodont
Res (2017), https://doi.org/10.1016/j.jpor.2017.09.005