Deep margin elevation

Deep margin elevation is a "must-know" in complex Class II restorations. In this webinar, we will share the biomaterials used and techniques.

[@aaronreimer1869]

Dental student here, thank you so much for the video it’s so inspiring!! Hope to be able to try these techniques!

[@davefoster5911]

The last case is technically exceptional and a wonderful service for your patient 👍🏻

[@raulsimmylv]

Thanks a lot doc .I missed live though I registered .you are an excellent teacher

[@libyetiger4270]

I absolutely appreciate your webinar ❤️❤️❤️ you do not know how much it helps me Thank you doctor ❤️

[@romerodentalseminars]

We do it for people like you! Thank you so much for watching. Please share our channel with other colleagues. Best Mario

[@haeunhyun3734]

great tip doctor! Any tips on when to use RMGI vs. Flowable for GME?

[@ahmadwwe2010]

Thank you so much, Great video

[@ashkanershadi6395]

Thank you Doc. How did you create/form the matrices from the waxup?

[@wewereads]

thank you soooooooo much for sharing please keep going .. love from sudan

[@user-fishodontist]

thanks a lot doc very helpful

[@user-js4kd8fu8y]

Very helpful, as usual. Thanks a lot. I have a few questions... 1. If you're gonna do a direct restoration, why do you have to place an RMGIC base instead of composite, I mean, if you can place the RD and achieve proper isolation, is there any advantage for RMGIC over composite? 2. In the severely broken-down premolar case, how did you place a band for DME? 3. Do you have endodontic series? Your webinars area so useful clinically, it would be most helpful if you had endodontic series, too.

[@romerodentalseminars]

1. That is a good point, decision making factor? Caries risk. 2. Free handed buccal and lingual, band for M and D. 3. I hate endo hahahaha, all referred to the pros’

[@omarmanaa534]

Great informing video as usual Dr. I have been following you for a while and i really really enjoyed these seminars and trying to step up my rubber dam game using your tips I just find it hard to invert the rubber dam in sub gingival areas like in 43:00 although i know the tips but clinicaly it is not that easy So can you implement a short video "during" isolation of such cases as in 43:00 It would be much easier to notice the tricks while in action Keep up the good work ♥️

[@romerodentalseminars]

Omar, thank you for your kind words. I am happy to know you enjoy our webinars. I totally agree with you when you say “it is not easy” to perform the more complex isolations but I really good advice I can give you is don’t let this stop you. I personally struggled for a while before becoming good and the only reason I can Isolate almost every clinical situation today and a because I practice every day! I will create a new webinar with some videos this 2022 as per your request!

[@romerodentalseminars]

Will do! Thanks for watching

[@noechaparro7312]

In the last example did you free hand part of the margin elevation? I didn't see a band placed in the beginning.

[@xavierleung2737]

Thank you for the very useful and detailed explanation on this interesting topic. I’m wondering in case when you have a very deep margin and there’s root concavity in the middle portion of the margin, how to make sure the band adapt well to the concavity?

[@romerodentalseminars]

You can modify the anatomy using a diamond bur. Sometimes we need to flap and then place rubber dam, elevate, remove dam and suture. All depends on the complexity of the case but the GOAL, is to restore and save teeth.

[@judeel-mohamad5698]

I just finished dentistry school and there is a fundamental rule that we are teached, that is breached when doing deep margin elevation for indirect restorations: Margins for a indirect restorations must always be on the tooth. How come that we now endorse having a composite margin when performing a crown prep? Thanks!

[@romerodentalseminars]

This is called “reality” and I promise you, you will be confronted with many situations like this. This is only one more option that is supported by evidence . Good luck in this wonderful career.

[@andrewchen9560]

Thanks for sharing this amazing lecture to us! A quick question here:How to do DME on the second molar distal caries?(No third molar exist) I have a big problem on applying rubber damn.The distal margin just can’t show up,and that’s quite frustrating 😔 Is there any tips for such situations?

[@romerodentalseminars]

Sometimes a 12A or 13A clamp is helpful, but if you find it to be “imposible” my advice is for you to use cotton roll isolation and concentrate on elevating the distal margin only using RMGI. Then isolate with RD and continue procedure. Hope this helps

[@Docpietrosavage007]

Thank you doctor.

[@romerodentalseminars]

You are welcomed!

[@abdennourchalal5812]

Great content! Thanks you doctor. But I'm a little bit confused, watching other videos about indirect emax restauration, all of them say that it must be bonded on RMGIC, but you say that composite is the materiel to use in indirect cases. Can you please explain?

[@romerodentalseminars]

If bonding steps are performed under IDEAL conditions, bond strength of composite is much higher than RMGI. Another benefit of resin is its insoluble, this is crucial when you are using a long term solution as a restoration. Thanks for watching.

[@amrmaher8609]

Great Lecture Doctor pretty inclusive and your work is impressive ! I was wondering if you could tell me what is the difference bw composite and resin composite ?

[@romerodentalseminars]

Thank you for your kind words and for watching. No difference between words.

[@javierrodriguezsepulveda6454]

Amazing Seminar! First time watching you’re videos, thank you so much for shearing knowledge. Greetings from Mexico 🇲🇽

[@benjaminadriano4371]

P

[@BeyondDentistry]

Beautiful documentation. I need to up my rubber dam game.

[@dongdongdong8413]

thank you

[@acash93]

I have been told that open sandwiches have higher rate of failures because of the difference in strain between glass ionomer cements & composite resins. How do you mitigate against this?

[@romerodentalseminars]

I have not found that to be true, on the contrary, GI are an excellent option when dealing with deep margins because of its chemical bond to tooth structure, because of its very low shrinkage due to its self curing properties and finally because of its ease of application when injected into the deep margin. Another thing I want to you to think about is “what other option do you have?” extraction? clinical crown lengthening and exposing more root surface and creating a larger embrasure? This are definitely not easy cases but I always try saving the tooth first! Hope this helps

[@krossvbzer8869]

Hello Doc wonderful video👍🏽 in min 45:15 how was it possible to elevate the margin with a wedge placed? Doesn’t it interfere with the emergence profile? Thank you very much for your lectures!

[@romerodentalseminars]

I don't use wages for my margin elevation, only after the margin has been elevated and for my proximal walls, that is when I use them. Thanks for watching.

[@delilasorrell3441]

Can you take molars and carve to fit where another molar is gone,like tooth right in front? I have put healthy teeth back in .

[@choochd]

Excellent tutorial Dr. Romero. How much would in-house CAD/CAM system cost on avg? Would you consider it instead of having to send it out to a lab?

[@romerodentalseminars]

Thanks for your comment and for watching. There are many “good” in house systems out there. The question is, how good are you at making these restorations look “natural”, How much time do you have to spend on the “lab” side of things? I prefer sending them to a comercial lab, but that is just my opinion.

[@Znb.ak000]

👌👌👌

[@andrewphillips4331]

Thanks for the video. My question is regarding DME with composite and then placement of a direct composite. If the margin is elevated with composite and then refined with a bur, then a sectional matrix placed, do we need to etch prime and bond again?

[@romerodentalseminars]

Great question and the answer is no, as long as you keep layering. Thanks for watching

[@manuelthomas3489]

Why is rmgic preferred for DME with direct composite, why not bulk-fill composite like indirect restorations, and vise versa ?

[@romerodentalseminars]

Determining factor, Caries risk.

[@aadilcassamally8213]

Amazing, what's the name of the fibres did you place in the canal in the premolar case?

[@romerodentalseminars]

Construct by Kerr

[@shahidmohammed5559]

thanks dear doc ,you are kind,my quetion is ,after placing flowable composite on the margin and finshing it with diamond bur ,the composite will be considered as old composite ,is it right ?so we follow old composite bonding procedure?

[@angelicafoster670]

rubber dam almost always gets stuck between the band and the margin in those cases of deep margin elevation, then after struggling for like 2 hours to isolate it , i turn it into a split dam technique to elevate that annoying inch, how do you get that perfect inversion in deep margins ? i tried floss ligature , but there is no space for the ligature to go apically , it tries to go above the margin. i'm really frustrated that deep margins are still that hard , my actual nightmare in the clinic and i tried everything from modified matrix to saddle matrix.

[@tolivich]

I have noticed that RMGIC usually have very weak bond with the tooth, and usually breaks off, dont you have that issue with your RMGIC given that you use it to elevate deep margins, I'm afraid to keep that as the margin base

[@romerodentalseminars]

That would be true if the RMGI would be placed of the occlusal surface, where it would he subjected to “loading”. For margin elevation is only 2-3mm RMGI height and then composite resin will be the material under occlusal load. This is not a new technique and it has been studied extensively.

[@user-pl5ls9yg4j]

Hello doctor, I would like to know if it's possible to send you some photos of my broken molar to tell me your opinion about making an overlay or fiber with crown. Thank you very much.😊

[@romerodentalseminars]

Yes, go ahead and email them to me at [e-mail]

[@angelicafoster670]

could glass ionomer be replaced by zinc polycaroboxylate for deep margin elevation and open sandwish tech? is the glass ionomer filling or cement in this case ?

[@romerodentalseminars]

No it cannot. Thanks for asking

[@WonderfulHoax]

Great webinar! How did you place a tofflemire band on the premolar while having a clamp on the tooth (43:30)? Or did you remove the clamp for the DME and then placed it back?

[@romerodentalseminars]

I used the automatrix combined with copper bands and the clamp in place. Thank you for watching

[@cathymartinet7771]

Good afternoon. What is the procedure for bonding the composite to the CVI? Just adhesive and composite, no etching? thanks ;)

[@romerodentalseminars]

CVI?

[@Benjaaatr]

@@romerodentalseminars It's gic in spanish. "Cemento de Vidrio Ionómero"

[@romerodentalseminars]

I do etch it, more to “clean” any debris left after smoothing the RMGI with a bur.

[@FMKification]

Par Excellence!!

[@whirl00]

Hello Doc, regarding the last case of using whole composite and fiber for the " long term temporary restoration". Did you remove occlusal contact, did you leave occlusal clearance?

[@romerodentalseminars]

Tooth is 100% functional and has been in place now for 3 years!

[@SamiGB1994]

But if i do not use the wedge while elevating the margin, will this make some kind of micro leakage there as we are not ensuring the tight contact between the modified matrix and the tooth?

[@romerodentalseminars]

There is nothing to “wedge against”. If you band is tight around the tooth, you should have no problem. Thanks for watching.

[@armanarmani5328]

Many Thanks for The Great Lecture . can we do DME on both mesial and distal for a single tooth such as upper first and second premolars specially when type of patient occlusion, is group function?

[@romerodentalseminars]

Yes you can. One or both boxes if indicated.

[@Dr.Yous96r]

Thanks for everything dr. My question to you are when and where I use gic or composite to do DME?? On what I depend to do the right choice??❤

[@romerodentalseminars]

RMGI can be used when the final restoration will be composite. Composite should be used if a ceramic restoration will be bonded as the final restoration

[@gregwarrior]

Great Work. Was wondering if you have any tips on elevating deep margins where only one side of the tooth requires elevating. For example the mesial proximal bony and soft tissue margin being normal at the cej level while the distal level are way below the cej. From my experience i found that it is very hard to use a circumferential band design because the mesial and distal levels have such a big depth difference.

[@romerodentalseminars]

Thanks for your question. I did mention in the webinar (Q&A session not included in the recording) that the band can be modify to compensate for that. You could also use a sectional matrix without the ring or wedge but rather keep in place using block-out resin (customized to your needs). As you can see there are multiple options in regards to bands but they all need to be modified. Hope this information helps.

[@tammimarie1898]

Is this advisable to do when the full crown has broken off with parts of the tooth still above the gingiva by a few millimeters, please?

[@romerodentalseminars]

If you are using biomimetic principles, yes! Thanks for watching.

[@natalystrem3135]

Great work Dr.Romero. How do you manage matrixband with clamb? Often clambs make great challenge for matrixband. Do you have some tips about that. Thank you.

[@romerodentalseminars]

Thank you for your comment. Please watch our basic and advanced rubber dam webinars. They are FREE and will answer your question regarding a clamp and matrix band.

[@yeeenchen3479]

Love the video! For the last case, what matrix did you use to build up the premolar circumferentially after adding fibres? Also, how do you make the matrix for buccal and lingual wall build up after waxing up? Thank you so much in advance!

[@romerodentalseminars]

I used a modified tofflemire and then fabricated a putty matrix guide from the wax-up and split it in half. Buccal and linguals half’s to be used intraoral. Hope this helps and thanks for watching. Dr. R

[@ilpensatoiodimarco5544]

why glass ionomer cement cannot rebuild proximal contact?

[@romerodentalseminars]

The number one reason is the difficulty in manipulating any GI to obtain a tight contact, why risk that when a composite is much easier to condense?

[@zainabshubber7141]

The best DME webinar I’ve watched 😊 thank you

[@romerodentalseminars]

Thank you very much for your kind words and watching our videos.

[@ghayasqasmi9364]

What rmgi do you use.

[@rawa2000]

What's the rationale behind placing composite with indirect restorations, why not place RMGI with indirect restorations?

[@paulchahal7545]

Student here. Do we still place the margins of the Lab fabricated crown on GIC should we go for DME? Shouldn't be the margins of the lab fabricated crown on solid tooth structure?

[@romerodentalseminars]

Ideally they should be on tooth structure. DME is reserved for cases when there is no other option than to elevate the margin, keeping in mind that is IDEAL isolation is not attainable, DME is not possible. Hope this helps

[@Turqay712]

Thank you Doctor! Very helpful webinar)

[@karamdabagh]

at 28:30 u can see the sheet between the band and tooth, it shouldnt be like that right?

[@gregors.5734]

Which material exactly are you refering to for RMGIC? For example, Rely X Unicem is a RMGIC in the USA, in Europe its a composite. On the other hand, Fuji Cem or Ketac Cem are RMGIC over here, but you obviously did not use those. Can you enlighten us on that subject or did I miss the part in the lecture? Many thanks and keep it up!

[@romerodentalseminars]

I am referring to something like Fuji II LC from GC AMERICA. Rely-X Unicem is not an RMGI, but 3M does make an RMGI that could be used , not sure what the “new name” is but Vitremer is an RMGI.

[@gregors.5734]

@@romerodentalseminars Thanks for your answer, its always funny how things get mixed up ( Rely X Unicem being a RMGIC or not)! Which deliverysystem do you prefer with your Fuji LC?

[@romerodentalseminars]

@@gregors.5734 Fuji II LC aplicap is the delivery system I prefer because it allows delivery of the material directly to the bottom of the box. Thanks for asking

[@Mahmoud-cp9hu]

@@romerodentalseminars do you agree to used preheated composite to elevate the margin for better adaptation ?? What is the name of the resin you are using from colten for DME ?? CAN YOU INFORM US MORE ABOUT THE RESIN FIBER YOU HAVE USED TO RESTORE THE BROKEN PREMOLAR ?? NAME AND THE WAY HOW TO USE IT ?? MANY THANKS

[@romerodentalseminars]

@@Mahmoud-cp9hu Nothing wrong with heated composite! Any brand works well.

[@gloriahersan6163]

Which specific kind of resin are gold stantards for deep margin elevation?

[@romerodentalseminars]

I use DC core build up material (ParaCore from Coltene) combined with a SC adhesive system (ParaBond from Coltene). I allow the core build-up to “self cure” for 4 minutes, prior to LC for 30 seconds. Thanks for watching

[@kokujo6125]

what if a patient needs a full crown with margin already elevated with rmgi then resin composite ? should i redo the margin elevation process with resin composite ?

[@romerodentalseminars]

Yes, I would recommend to be re-done with composite only. Hope this helps. Thanks for watching.

[@antonrudenok79]

rubberdam is not panacea. But teflon is, i think.

[@SB-wy2wx]

Hey great lecture, just a question, when doing cervical margin relocation for indirect cases, when using resin long term wise, as the margin is subgingival, isnt it prone to hydrolysis + shrinkage stress, hence making it a higher risk for recurrent decay?

[@romerodentalseminars]

Bonding and polymerization are crucial for any composite restoration regardless of it location. Rubber dam isolation provides control of the operative field so it help with bonding. Selection of the appropriate composite will aid in degree of conversion. If you use a packable composite you need to make sure to control the layer thickness. If you use a bulk fill this may aide in avoiding lack of polymerization. All these aspects should be considered. Keep in mind that if you were to restore a tooth with an indirect restoration all the way down the deep margin you will still have a resin/ceramic interfase in an area that most likely you had no control of the fluids during polymerization. Thanks for watching

[@SB-wy2wx]

@@romerodentalseminars You make a fair point! Thanks for the reply!

[@yenhsiang0814]

GREAT

[@narimansaad4038]

In the last case, are the restored teeth functional?

[@romerodentalseminars]

Yes they are and we just obtained the 1.2 years follow up

[@narimansaad4038]

@@romerodentalseminars thanks for answering ☺️

[@user-rk9nr8vw3h]

❤

[@hibaqadi4225]

Why can’t use RMGI in contact?

[@theaprevot]

I would like to know too, please Doc. Thanks!

[@ivan-cb5dc]

First of all, thank you for this great webinar. I think it will soon make me addicted to all the other content on your channel. However, I did not understand the difference between the Closed Sandwich Tecnique and the Open one.

[@romerodentalseminars]

Hi Gianni, thank you for watching our webinars. The only difference is that in the "open" type the RMGI or GI are exposed to the oral environment. On the other hand, in the "closed" type these are covered completely by composite resin, so the RMGI or GI are within the preparation. Hope this helps.

[@martinchrom4444]

I think it is always better to end the restoration on tooth, not in composite...

[@carlcrutchfield5681]

Please elaborate.

[@romerodentalseminars]

Only if it could always be that way... nut unfortunately that is not reality.

[@martinchrom4444]

@@carlcrutchfield5681 Now, this is just how I view these kind of problems and my philosophy - In the end of the day, it is still a composite filling bonded to dentin, thermal expansion plays a factor there and there is a probability that it is gonna leak one day. Those properties are better with emax or zirconia directly on tooth. If I can put rubberdam and matrix on a tooth and isolate I should also be able to place the indirect restoration there. In case of deep margin, it is possible to do gingivectomy using electrocautery and convert the subgingival defect to supragingival, prep the tooth, rather for a conventional zirconia crown, take the impression and cement a provisional crown using a phosphate cement or caboxylate. For conventional cementing, only couple seconds of dry operating field are needed and it is easier than bonded restoration and makes my life easier. If however I necessairly need the bonded restoration, gingivectomy will allow the rubberdam to be placed under the prep line. The papila will grow back, maybe couple months but it will. Then, no one will know that gingivectomy was done. Reepitalisation in couple of weeks. If the defect is super deep, and I need to gain access to the margin or gain the ferrulle, surgical crown lenghtening comes to play, or ortho extrusion in one rooted teeth to gain ferulle. Speaking of ferrulle I have a pretty simple mechanism for crowns. I ask myself - do I have ferrulle or not? If not, is the root long enough and can I gain it? If I dont have it and I can gain it I choose one option out of 3 : surgical crown lenghtening, ortho extrusion or surgical extrusion. Precisely selected for the given case and circumstances. If there is no ferrulle and cannot be gained, I extract and dont risk root fracture. This way, I avoid composite margin elevation and end the restoration on tooth. Also combining composite margin elevation with emax onlay is a problem, there is a difference in module of elasticity, the composite under the emax is more springy and it can cause the emax to break beacuse it is harder and more brittle. Like a matress in between. Also bonding to an old composite, where the oxygen inhibited layer has been removed is weak.

[@carlcrutchfield5681]

@@martinchrom4444 very thorough explanation. I used to have a similar philosophy, but the work done by Spearfino, Dietschi, Magne, and others not presented in this video have convinced me that with proper isolation and technique margin elevation is another viable option to consider. In the end, we all choose to practice how we feel will best benefit our patients and be manageable and cost effective. Continued success to you Dr.

[@kimnewcom]

I don't agree with this. Indirect restoration such as crown or onlay must rest on the tooth surface. Just do some gingivectomy or crown lengthening.

[@romerodentalseminars]

You don’t have to agree, but there is enough evidence to support it. Thanks for your comment.