Q U I N T E S S E N C E I N T E R N AT I O N A L

RESTORATIVE DENTISTRY

Andrej M. Fabian Philipp

Kielbassa

Restoring proximal cavities of molars using the

proximal box elevation technique: Systematic review
and report of a case
Andrej M. Kielbassa, Prof Dr med dent Dr h c1/Fabian Philipp2

Objective: For decades, dental restorative treatment of large that flowable composites allow for a stepwise elevation of
and deep cavities of posterior teeth has been adequately proximal cavity floors, thus simplifying treatment of deep
ensured by amalgam or by indirect gold restorations; with the lesions, and broadening the restorative spectrum. A case
continuing advancements in material technology and clinical report revealing an advanced caries lesion and demonstrating
techniques, alternative and more esthetic types of restorations the clinical application of the PBE technique together with an
have become feasible. Proximal box elevation (PBE) using com- indirect computer-aided design/computer-assisted manufac-
posite resins has been advocated for relocating subgingival ture (CAD/CAM) all-ceramic restoration is presented, assuring
cavity outlines; treatment success and effects of PBE require the practitioner’s familiarity with effective placement tech-
documentation. Data Sources: An electronic search was per- niques. Conclusion: PBE represents a promising two-step
formed on several literature databases to identify relevant treatment regimen, simultaneously encompassing the benefits
articles published in indexed journals until April 2015. Method of immediate dentin sealing and facilitating direct or indirect
and Materials: The authors independently screened the rele- adhesive restorations of cavities with margins located beneath
vant papers found (PBE with composite resins). Results: This the gingival tissues. However, high-quality randomized clinical
paper compiles the current knowledge about PBE (which is trials are required to confirm the laboratory outcomes.
predominantly based on laboratory research, in particular with (Quintessence Int 2015;46:751–764; doi: 10.3290/j.qi.a34459)
a focus on microleakage and marginal adaptation), revealing

Key words: advanced caries lesion, caries diagnosis, CEREC, gingivitis, margin relocation, open-sandwich restoration,
proximal box elevation, proximal margin elevation technique

With the designated phase-down of amalgam as a rou- lating remineralization) and microinvasive approaches
tine treatment regimen for posterior teeth,1 in particu- (including the infiltration technique)2 will be empha-
lar preventive (hampering demineralization and stimu- sized to avoid any surgical treatment. However, when it
comes to increased demineralization (along with sur-
1
face breakdown), timely invasive options for posterior
Professor and Head, Centre for Operative Dentistry, Periodontology, and
Endodontology; and Dean, University of Dental Medicine and Oral Health, Dan- class II cavities include the use of directly placed com-
ube Private University (DPU), Krems, Austria.
posites,3 together with adhesively bonded indirect res-
2 Undergraduate Student, University of Dental Medicine and Oral Health, Danube
Private University (DPU), Krems, Austria. torations. In many western countries, an increasing
Correspondence: Prof Dr Dr h. c. Andrej M. Kielbassa, Centre for Opera- public demand for esthetic solutions can be observed,
tive Dentistry, Periodontology, and Endodontology, University of Dental and this has been accompanied by a continuous devel-
Medicine and Oral Health, Danube Private University (DPU), Steiner Land-
straße 124, 3500 Krems, Austria. Email: andrej.kielbassa@dp-uni.ac.at opment of tooth-colored materials and luting agents

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leading to an increasing use of direct and indirect elevating the proximal box floor as described by Dietschi
esthetic restorations of posterior teeth. This trend and Spreafico12 may be an option. The recently reevalu-
towards non-amalgam restorations has been assisted ated process flow in such cases involves the application
by a significant increase in teaching and training in the of a composite resin using a diligent layering technique
use of amalgam alternatives in many dental schools.4 to relocate the cavity margins from deep proximal areas
Unfortunately, along with the more frequent use of with the aim to facilitate rubber dam application (fol-
adhesive techniques, new clinical problems have lowed by a direct or indirect restoration),13 thus ensuring
appeared. Proximal caries and cavities of large dimen- that oral fluid control is possible and reducing possible
sions extending below the cementoenamel junction stress effects from polymerization shrinkage.14,15 In the
(CEJ) and revealing cavity margins located beneath the current literature, this technique has been named prox-
gingival tissues appear to be challenging, since cavity imal box elevation (PBE),13,16-18 proximal margin eleva-
preparation, impression taking, adhesive bonding pro- tion,19 margin relocation,20-22 or open-sandwich tech-
cedures, and proper moisture control might be nique.14,23-25 The objective of this paper is to review the
impeded. Additionally, with a deep proximal box the scientific backgrounds of the PBE technique, to discuss
usage of indirect all-ceramic restorations often is ham- possible benefits and potential drawbacks, and to pres-
pered (if not considered impossible). It is generally ent a clinical case considered representative.
accepted that contamination with blood5 and/or saliva6
during bonding and cementation procedures weakens
the adhesive bond strength and leads to a possible
METHOD AND MATERIALS
failure of the restoration. Therefore, with deep proximal Search strategy
cavities it is vital to master these clinical steps and to This review’s methodology was adopted from PRISMA
achieve marginal integrity, which is considered one of (Preferred Reporting Items for Systematic Reviews and
the most important criteria for restoration success. Meta-Analyses).26 An electronic search with no restric-
In cases with large posterior defects, restorations tions regarding dates was performed on EBSCOhost,
fabricated from indirect CAD/CAM (computer-aided EMBASE, PubMed/MEDLINE, and Scopus (up to April
design/computer-assisted manufacture) techniques 2015). The search was completed by use of Google
have proven to be very reliable over long-term periods Scholar, thereby cross-checking the results for relevant
of up to 18 years,7 with survival rates very comparable publications in indexed journals; Google Scholar pro-
to direct composite restorations,8 with restoration mar- vides some advantages over other retrieval systems like
gins better than with direct composite fillings,9 and easy initial retrieval of possibly worthwhile articles and
with acceptable esthetic outcomes even with under- the ability to find citations to older items.27 The main
graduates.10 Furthermore, the use of chairside CAD/ search terms were “margin relocation”, “proximal box
CAM systems enables the clinician to process all-ce- elevation”, “proximal margin elevation [technique]”,
ramic restorations in a single visit. This is considered and “open-sandwich [technique or restoration]” (with
advantageous, since, from a biologic point of view, the composite resin restorations below the CEJ of perma-
immediate dentin sealing (IDS) will avoid any bacterial nent teeth). In addition, reference lists of potential
contamination during the provisional phase. Teeth publications to be included in the review were
restored with bonded ceramic inlays show biologic explored for other relevant papers.
compatibility, adequate compressive strength, similar
thermal conductivity to dental tissues, marginal integ- Selection criteria
rity, and color stability.9,11 This review sought for in vitro studies and randomized
To make treatments in those cases less fault-prone, controlled trials (RCTs) on PBE and related terms in per-
the application of a composite resin attached to and manent teeth (see above). Publications not focusing on

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restorations beneath the gingival tissues or the CEJ Marginal adaption: in vitro studies
were excluded. In total, 13 of the 15 studies13,16,18-20,24,25,28-33 focused on
indirect or direct restorations. The investigated speci-
Screening process mens underwent a thermomechanical load-
The two review authors performed the search and ing,13,16,18-20,24,30 or a thermocycling procedure23-25,28-33 to
selection process (finished on 11 April 2015). After the simulate in vivo conditions, and to draw any conclu-
initial screening of titles and abstracts, full papers were sions about the potential clinical longevity of the ma-
analyzed, and differences between the reviewers were terials used. This may elucidate an initial tendency on
resolved through discussion. the clinical adequacy of the PBE technique. No signifi-
cant differences between elevated and non-elevated
margins of proximal boxes could be ascertained, either
REVIEW RESULTS by means of microleakage testing,23,25,32 or by using
Literature search SEM techniques to evaluate marginal integrity.13,16,18-20,22
The initial search yielded 30 available titles in EBSCO- However, the available literature contains substantial
host, 32 in EMBASE, 87 in PubMed/MEDLINE, and 41 in controversy about preferred base materials; while some
Scopus, with four papers (double or multiple retrievals) authors have recommended (resin-modified) glass ion-
found in all databases mentioned. In total, 170 studies omers (primarily because high-caries-risk patients
not fitting the eligibility criteria of this review were might benefit from the material’s fluoride release, but
excluded after careful reading. Thus, 19 studies pub- with high dissolution rates),14,37,38 others have favored
lished between 2003 and 2015 were included in this flowable composite resins (with a lower modulus of
review. In total, the search resulted in 15 in vitro stud- elasticity) since microleakage was decreased compared
ies, three in vivo studies and one in vitro/in vivo com- to other materials.28-30,32
parison relevant to the topic. A summary of all in vitro
studies included in the current paper is provided in Effects on fracture resistance: in vitro studies
Table 1. Due to the low number of clinical trials and the Root canal treatment had no significant influence on
heterogeneity of the in vitro studies included, further the marginal adaption or the fracture resistance of the
statistical analyses were not considered appropriate. specimens.16 Fracture resistance was increased by
applying a flowable composite liner in Class 2 amalgam
Study characteristics restorations.24
The characteristics of the included studies are shown in
Table 1. With the 15 selected in vitro studies, a total of Other observations: in vitro studies
672 human teeth were treated and analyzed. Most A delayed light-curing procedure could decrease
papers referred to the marginal adaption and/or the microleakage according to some authors.25,28,31 With a
microleakage of the relocated cervical mar- similar effect, soft-start polymerization was tested,
gins.13,16,18-20,22,23,25,28-33 The marginal adaption was showing no leakage in enamel margins and producing
assessed by examining gaps between tooth tissue and similar values to those of conventional techniques for
restoration using scanning electron microscopy (SEM) dentin margins.33
using epoxy resin replicas. Microleakage was measured
by using dye penetration methods. Moreover, fracture Complications: clinical trials
resistance and effects of delayed light curing were Mechanical complications such as fractures of restor-
examined.16,24,25,28,31,33 Only four papers reported clinical ations (compomer-based PBE vs direct composite resin
data,14,15,34,35 with follow-ups from 2 months36 up to 9 restoration) could not be observed after 3 years of
years, whereas two of them had the same basis.14,15 observation,15 and were reported in only two cases

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Table 1 Compilation of in vitro studies dealing with PBE: experimental design and main
outcome of restoration of cavities with proximal margins located below the CEJ are given

Research objec- Human Preparation Secondary restor-

Study tives specimens design ation material Base lining
Atlas Effect of No restorations Dual-cured composite (DC Core Automix) as base,
50 molars Class 2
et al25 light-curing delay placed light-cured composite (Clearfil AP-X) on top

Rodrigues
Microleakage/ 32 third Composite resin Composite resin (Filtek Z-250), amalgam (Logic Plus),
Junior et Class 2 (box only)
marginal integrity molars (Filtek Z-250) RMGIC (Vitrebond)
al33

Fabianelli Microleakage/ Class 2 Composite resin

30 molars Flowable composite resin (Palfique Estelite LV)
et al32 marginal integrity (mesial-occlusal) (Estelite Sigma)

Kamath Effect of Composite resin

35 molars Class 2 (box only) Dual cured composite (Rebilda-DC)
et al31 light-curing delay (Polofil supra)

Silorane composite (Filtek Silorane), composite resin

(Clearfil Majesty Posterior, Clearfil AP-X), flowable com-
Lefever Class 2 (mesial- No restorations
Marginal integrity 88 molars posite resin (Clearfil Majesty Flow), self-adhesive resin
et al22 occlusal-distal) placed
cement (RelyX Unicem), bulk-fill composite (SDR),
flowable self-adhesive composite (Vertise Flow)

Composite resin
Roggen- Marginal 40 third Class 2 (mesial- inlays (lab-made Self-etch cement (G-Cem, Maxcem Elite),
dorf et al18 integrity molars occlusal-distal) Clearfil Majesty composite resin (Clearfil Majesty Posterior)
Posterior)

Self-adhesive resin cement (RelyX Unicem), dual-cure

Franken- Feldspathic ceramic
Marginal 48 third Class 2 (mesial- self-adhesive universal resin cement (G-Cem), self-etch
berger inlays (IPS Empress
integrity molars occlusal-distal) self-adhesive resin cement (Maxcem Elite), composite
et al13 CAD)
resin (Clearfil Majesty Posterior)

Güray Amalgam (World

Fracture 48 third Class 2 (mesial- Glass ionomer (Ionoseal) or flowable composite
Efes Cap) or composite
resistance molars occlusal-distal) (Filtek Supreme XT Flowable)
et al24 (Filtek Supreme XT)

Feldspathic ceramic
Zaruba Marginal 40 human Class 2 (mesial-
inlays (Vitablocs Composite resin (Tetric)
et al19 integrity molars occlusal-distal)
Mark II)

Microleakage/ Composite resin

Bhanwal Flowable composite (Swiss TecFlow-Coltene)
effect of light 40 molars Class II (box only) (Synergy
et al28 or dual cure composite (Para Core-Coltène)
curing delay D6-Coltene)

48 mandib- Feldspathic ceramic

Marginal integ-
ular molars inlays (Vitablocs
Ilgenstein rity/fracture resis- Class 2 (mesial-oc-
with root Mark II) or compos- Composite resin (Tetric EvoCeram)
et al16 tance with root clusal-distal)
canal treat- ite resin inlays (Lava
canal treatment
ment Ultimate)

Marchesi Ceramic inlays (IPS

Marginal integrity 10 molars Class 2 Composite resin (Filtek Supreme XTE Flow)
et al20 e.max CAD)

Compomer (Compoglass F), flowable composite resin

Moazzami 50 pre- Composite resin (Tetric Flow), self-cure composite resin (Degufill SC),
Microleakage Class 2 (box only)
et al29 molars (Tetric Ceram) RMGIC (Fuji II LC Improved), composite resin (Tetric
Ceram)

Sawani Nano composite Flowable composite (Filtek 350 XT flow), RMGIC (Vitre-
Microleakage 53 molars Class 2 (box only)
et al30 resin (Filtek 350 XT) bond)

Shafiei
and 60 maxillary Composite resin
Microleakage Class 2 (box-only) Composite resin (Filtek Silorane)
Akbar- premolars (Filtek Silorane)
ian23

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Test procedure Outcome

Thermocycling (2,000 times
All delayed-cured groups performed better
between 5°C and 55°C)

Thermocycling (500 times None of the materials used could prevent dye penetration in dentin; composite resin and soft-start technique pro-
between 5°C and 55°C) duced the least microleakage

Thermocycling (500 times

Better marginal adaption with open sandwich technique
between 5°C and 55°C)

Thermocycling (500 times

Reduced microleakage with delayed light-curing
between 5°C and 55°C)

No Best marginal adaptation was exhibited by Clearfil Protect Bond/Filtek Silorane Bond/Filtek Silorane

Thermomechanical loading
Bonding composite resin inlays directly to dentin showed similar amounts of gap-free margins in dentin compared
(100,000 × 50 N; 2,500 times
to PBE
between 5°C and 55°C)

Thermomechanical loading
(100,000 × 50 N; 2,500 times PBE with self-adhesive resin cements exhibited significantly more gaps in dentin than with composite resin
between 5°C and 55°C)

Thermoloading (5,000 times

between 5°C and 55°C), Better absorption of tooth flexure forces with PBE
fracture resistance tests

Thermomechanical loading
(1,200,000 × max. load 49 N; PBE before insertion of a ceramic inlay results in marginal integrities not different from margins of ceramic inlays
6,000 times between 5°C and placed in dentin
55°C)

Thermocycling (1,000 times

PBE significantly decreased microleakage if compared to restorations without PBE
between 5°C and 55°C)

Thermomechanical loading
(1,200,000 × 49 N; 3,000 times PBE had no impact on either the marginal integrity or the fracture behavior of the specimens
between 50°C and 5°C)

Thermomechanical loading
(240,000 × 50 N; 7,800 times Marginal integrity was not affected by PBE
between 5°C and 55°C)

Thermocycling (1,000 times

Incremental technique with composite resin had the least microleakage; RMGIC had the most microleakage
between 5°C and 55°C)

Thermocycling (500 cycles

PBE with flowable composite resin performed slightly better than RMGIC
between 5°C, 37°C, and 55°C)

Thermocycling (1,000 times

Best cervical marginal seal was obtained by total bonding with silorane composite
between 5°C and 55°C)

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Fig 1a Preoperative (buccal) view of the 26-year-old man. Clin- Fig 1b Immediately after probing, increased bleeding from the
ically, neither plaque nor signs of caries (see normal enamel proximal site of the permanent left second maxillary molar could
translucency and texture) were visible. Gentle probing using a be observed, suggesting severe papillary inflammation and indi-
WHO probe did not reveal any increased attachment loss. cating an active and progressing caries lesion.

Fig 2a Initial bitewing radiograph revealing an advanced prox-

imal caries lesion at the mesial aspect of the permanent left sec-
ond maxillary molar (note that cavitation of proximal surface is
not identifiable with this diagnostic imaging technique, thus
highlighting the problem of conspicuity resulting from depicting
a 3D structure with a 2D image (compare Fig 2b).
Fig 2b Corresponding preoperative CBCT scan (buccal view),
showing the dimension of the proximal caries lesion. Note cervical
lesion extension indicating that cavity floor of proximal box will
be in the immediate vicinity to the surrounding periodontal tis-
sues and the alveolar crest; advanced lesion progress has led to
breakdown of enamel integrity, and cavitation is clearly visible if
a b compared to the conventional radiograph (compare Fig 2a).

after the 9-year evaluation.14 However, biologic compli- dental care. An extraoral examination revealed no
cations such as secondary caries were observed in eight swellings, asymmetries, or sensitivities in the head and
cases.14 Notwithstanding, no group indicated a higher neck areas. The mucosae were healthy pink, non-in-
number of mechanical complications due to a specific flamed, and showed no macroscopic signs of lesions or
technique, and no clinical advantage was attributed to ulceration. Periodontal screening revealed non-in-
any of the techniques used.14 This was corroborated by creased probing pocket depths; however, bleeding of
a 6-year clinical study (comparing two different adhe- the gingiva after gentle probing of the mesial site of
sive/composite resin systems); here, neither recurrent the left second maxillary molar was observed (Fig 1).
caries nor discolorations were detected.34 None of the The clinical examination of the asymptomatic and vital
included clinical papers focused on gingival or peri- tooth revealed a small surface defect located at the
odontal effects. central groove, with signs of active caries and occlusal
surface breakdown.
A bitewing radiograph (Heliodent Plus, Sirona Den-
CASE REPORT tal Systems; 68 kV/0.08 s) revealed a deep manifest
A 25-year-old Caucasian man with a complete dentition lesion, obviously non-cavitated but progressing into
presented to the outpatient clinic (Danube Private Uni- dentin and undoubtedly requiring restorative treat-
versity, Krems, Austria) for a routine dental check-up. ment (Fig 2a). Additionally, cone beam computed
His medical history was non-contributory to routine tomography (CBCT, Galileos; Sirona Dental Systems)

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Fig 3a Preoperative CBCT Fig 3b Preoperative occlusal Fig 3c Intraoperative view Fig 3d After meticulous iso-
scan (occlusal view), corrobor- view (with localized surface showing that isolation with lation of completed cavity
ating caries extension in pulpal defect/microcavity of the cen- rubber dam did not prevent preparation, the proximal box
direction and breakdown of tral groove) after disinfection of from excessive bleeding, due was isolated using a Tofflemire
proximal enamel surface (com- the operating field and rubber to subgingival extension of matrix band and a wooden
pare Fig 2). dam placement (note that at proximal box floor. wedge to ensure tight proxim-
this clinical level detection of ation. Dentin bonding using a
the advanced stage of proximal three-step adhesive followed
caries was not possible). after acid etching.

was used for imaging the jaws (for presurgical examin- Due to the subgingival extension of the proximal
ation of an impacted right mandibular third molar), and box floor, isolation with rubber dam did not prevent
a 14-second standard scan was performed. The CBCT excessive bleeding (Fig 3c). Therefore, a circumferential
examination revealed an advanced proximal caries stainless steel matrix fixed in a Tofflemire retainer,
lesion (close to the pulp as well as propagating towards along with a wooden wedge (Hawe, Kavo Kerr Group)
the CEJ), with a clear surface breakdown of mesial sur- to ensure tight proximation, were used to achieve iso-
face (Figs 2b and 3a). lation for the PBE procedure. Additionally, the teeth
Due to the patient’s tight time schedule, a chairside were isolated with cotton rolls, and a dry-angle was
treatment using the Cerec system (Sirona Dental Sys- placed to prevent from excessive salivary flow. To
tems) was proposed and consented. With regard to the ensure an optimal workflow a flexible saliva ejector was
radiographic caries extent, the restorative plan in this permanently used with utmost attention to prevent
case included a possible PBE to relocate the proximal saliva contamination and to facilitate the operative pro-
margins (if necessary), followed by the adhesively cedures.
cemented all-ceramic inlay. Enamel was selectively etched for 30 seconds, and
total etching followed for 10 seconds with a 37% phos-
phoric acid gel (Total Etch, Ivoclar Vivadent). To seal the
CLINICAL PROTOCOL freshly cut dentin surfaces immediately after tooth
After local anesthesia, rubber dam was placed and a preparation, a three-step dentin bonding agent (Syntac
wax floss ligature was tied around the adjacent molar Primer, Ivoclar Vivadent) was applied onto the cavity
to secure the rubber dam subgingivally (Fig 3b). The floors with a gentle brushing motion for 20 seconds
first clinical procedure comprised a careful opening of (Fig 3d), followed by application of adhesive (Syntac
the caries lesion with diamond burs (846; Komet Bras- Adhesive, Ivoclar Vivadent) and unfilled resin (Helio-
seler) under sufficient water cooling. Complete caries bond, Ivoclar Vivadent) being light-cured for 20 sec-
removal was accomplished using bud burs (H1SEM; onds (1,200 mW/cm2; Silverlight, GC). A base of flow-
Komet) compatible with the size of the cavity at low able composite resin (G-ænial Universal Flo, GC) to
speed. Although the lesion was located close to the relocate and uplift the cervical margin to a supragin-
pulp, exposure was avoided and direct pulp capping gival level and to block out undercuts was then
was not necessary. applied, accompanied by small portions of a filled vis-

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Fig 3e Application of both Fig 3f After final polymeriza- Fig 3g Virtual construction Fig 3h Final preparation
flowable and viscous compos- tion was accomplished using a after optical scanning/digital design, with relocated prox-
ite resin. Note that adequate light source operating at 1200 impression of ceramic inlay imal margin. Rubber dam was
isolation was achieved, and no mW/cm2, finishing of the prox- using CAD/CAM chairside re-placed below the new cavity
contamination occurred. imal margins followed with technology. outline, thus enabling further
polishing strips. processing of restoration with-
out risk of contamination (and
allowing optical scanning/dig-
ital impression, if necessary).

Fig 3i Try-in of the CAD/CAM- Fig 3j For safe bonding, PBE Fig 3k Final clinical view of Fig 3l Clinical appearance 3
generated adhesive ceramic composite resin was primed. finished restoration (perma- months after treatment. Patient
inlay restoration. Ceramic inlay was etched and nent left second maxillary was satisfied, and did not
silanized, and adhesively luted. molar). Intact fissures with ini- report any signs of discomfort.
tial but non-undermining car-
ies (compare Fig 3h) were
simultaneously sealed.

cous composite resin (G-ænial, GC; Fig 3e). After light decreasing grit and polishing strips (Epitex, GC; Fig 3f).
curing for 40 seconds (Silverlight, GC) the matrix was Finally, rubber dam was removed and a digital impres-
removed and the preparation was finished with focus sion using the Cerec Omnicam (Sirona Dental Systems)
on optimum all-dimension thickness of the ceramic, was made. Optical scans of the antagonist teeth fol-
sufficient wall thickness of the tooth, carefully round- lowed for adjustment of the static occlusion. After veri-
ed-off inner transitions, and obtuse angles of prepar- fying the final restoration design (Fig 3g), the inlay was
ation margins to allow for accurate digital scanning of milled from a ceramic block (IPS Empress CAD, A2 I8;
the prepared cavity. The preparation was finished using Ivoclar Vivadent) using a Cerec MC XL Milling Unit
bucket-shaped diamond burs with rounded shoulders (Sirona Dental Systems). After re-application of rubber
(8847KR, 8845KR; Komet) to remove the oxygen layer dam (Fig 3h), try-in of the polished restoration fol-
and to provide ideal taper; simultaneously, enamel lowed, presenting adequate fit (Fig 3i). For safe bond-
margins were carefully re-finished, thereby removing ing, the PBE composite resin was primed (GC), and the
excess adhesive resin. ceramic inlay was etched and silanized (IPS Ceramic
Finishing of the elevated proximal margins was Etching Gel and Monobond Plus; Ivoclar Vivadent);
accomplished using flexible disks (Sof-Lex, 3M Espe) of finally, the indirect ceramic restoration was adhesively

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luted (Total Etch, Syntac Primer/Adhesive, Heliobond, restorations in areas difficult to access, to reduce frac-
and Variolink II A1; Ivoclar Vivadent; Fig 3j). ture susceptibility, and to increase the marginal adap-
After rubber dam removal, any retained excess resin tion of Class 2 restorations, by applying a (long-lasting)
cement remnants were removed, and appropriate base beneath the restoration which is open to the oral
tightness of proximal tooth contact was confirmed with environment. It has been suggested that such restor-
a sticking Tofflemire matrix (50 μm; Hawe). Static and ations might reduce secondary caries incidence due to
dynamic occlusion were evaluated using articulating good marginal sealing.23 However, some of the studies
paper (Arti-Check, 40 μm; Bausch). Dental floss was included in the current review did not support the use
passed interproximally to ensure patency and ability for of certain materials classes (such as [resin-modified]
oral hygiene by snapping in and out with firm resis- glass ionomers).13,16,18,22 Clinically relevant differences
tance. Finally, the restoration was polished using could be detected when using self-adhesive resin
ceramic polishers (187–189; Komet), followed by a dia- cements (Maxcem Elite, Kerr), and these obviously were
mond polishing paste (DirectDia, Shofu Dental) and a not suitable for PBE.13 However, with a meticulous lay-
brush (Jiffy, Ultradent) until a smooth transition from ering technique and bonded composite resin, it was
the tooth surface onto the restoration was assured concluded that PBE could be an alternative to conven-
(Fig 3k). To complete the treatment a fluoride gel (Sen- tional adhesive luting to dentin,13 with satisfactory
sodyne Proschmelz Fluorid Gelée, GlaxoSmithKline) performance in terms of wear of occlusal and proximal
was applied topically, and the patient received motiva- contacts.42
tion and oral hygiene instructions. The 3-month fol- Marginal gaps along the interface between restor-
low-up is shown in Fig 3l. Figure 4 presents the buccal ation and cavity floor and walls are considered stagna-
view, highlighting the non-inflamed papilla. tion sites for biofilm accumulation and retention; more-
over, microleakage is considered a major concern, when
it comes to factors affecting the longevity of a restor-
DISCUSSION ation. With timely bonding agents, no clinically consid-
Basically, PBE is not a new treatment regimen, since the erable complications like discolorations or secondary
principle behind this restorative procedure refers to the caries were detected in a previously published prospec-
open-sandwich technique. Essentially, PBE and tive clinical trial after 6 years,34 even if the simultane-
open-sandwich technique describe the same proced- ously performed in vitro study (using water storage and
ures. With the conventional open-sandwich restoration, thermomechanical loading) revealed a significant
a substantial part of the restoration was replaced with decrease of gap-free dentin margins with Class 2 prox-
a glass-ionomer cement (GIC), the latter covering sub- imal boxes.34 To improve marginal adaptation of PBE
stantial parts of the exposed dentinal surface of the restorations (with decreased microleakage and fewer
cavity, and extending to the periphery of the proximal voids), the use of flowable composite resins has been
box to form a new cervical seal (being exposed to the advocated.24,32 Moreover, when using (dual) cured com-
oral environment).14 However, with the open-sandwich posite resins as a base on the proximal box floor,
technique using GIC, high clinical failure rates have delayed light curing25,31 or soft-start polymerization33
been reported,39,40 and, thus, modifications using res- seems to be advantageous, possibly due to an improved
in-modified GICs, polyacid-modified composite resins, arrangement of the composite molecules, and thus
or low viscosity (flowable) composite resins have been leading to (polymerization) stress release.33 This sheds
introduced later on with acceptable outcomes in the some light on the viscous composite resins’ penetration
long term.14,15,41 ability which is increased with additional time.43
The main clinical aims behind both the PBE and the With proximal cavities of large and subgingival
open-sandwich technique, are to facilitate adhesive dimensions, handling difficulties are very common, and

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Fig 4a Clinical appearance 3 months after diagnosis and invasive Fig 4b Immediately after probing, no bleeding could be
treatment of caries lesion. Probing did not reveal increased prob- observed from the proximal gingiva, suggesting that periodontal
ing depths, and no clinical signs of papillary inflammation recur- tissues were healthy and tolerated violation of biologic width.
rence could be observed (compare to Fig 1).

these are due to inferior cavity inspection and access, niques, but extrapolation to the in vivo situation
deficient management of undercuts, hampered pro- remains difficult. For example, it is well known that
cessing of proximal margins, and limited moisture resin-modified GICs or polyacid-modified composite
control. Not astonishingly, these areas could cause resins (absorbing water/showing hygroscopic expan-
problems with regard to imperfect restorations pro- sion) have inferior mechanical properties when com-
moting plaque accumulation and retention, thus lead- pared to composite resins, a comparably rough surface
ing to chronic localized gingivitis, periodontitis, and finish, and high solubility rates;41 however, these mater-
attachment loss. Consequently, crown and fixed/ ials have shown acceptable clinical results so far.34,35
removable partial denture work as well as amalgam Similar considerations may be taken into account
restorations have been associated with inflammation, for flowable composite resins. These materials have
alveolar crest resorption, and periodontal breakdown; been assumed to improve marginal adaptation and
however, this obviously was not associated with com- seal, and to act as a stress-absorbing layer beneath a
posite resins and glass ionomers.44 Accordingly, the filled hybrid composite resin restoration. However,
amount of plaque and the degree of gingivitis adjacent these flowables also have inferior mechanical proper-
to (polished) composite fillings were not significantly ties. From Table 1, it seems clear that the effects are
higher than those for the GIC and enamel surfaces.45 material dependent, with either positive24,28,32 or nega-
With resin-modified GICs, compomers, and composite tive29,30 outcomes when placed underneath conven-
resins, this was corroborated; here, the various mater- tional hybrid composites.
ials did not result in measurable differences concerning These thoughts directly lead to the question of
clinical or subclinical signs of gingivitis.46 whether the biologic width will be affected by a PBE
These findings indeed seem to challenge merits and procedure.17 It is generally accepted, that violations of
clinical relevance of laboratory studies on microleakage the biologic width will result in gingival inflammation,
and marginal integrity (the latter representing the loss of periodontal attachment, and inflammatory bone
majority of non-standardized investigations compiled resorption. Notwithstanding, minor violations of lim-
in the current review; see Table 1). However, when scru- ited extent and with small but perfectly adjusted com-
tinizing the value of in vitro studies, it should be posite surface areas have been assumed to be non-det-
emphasized that the main advantage of such non-clin- rimental, in particular in cases of maintained oral
ical testing would seem the general differences among hygiene measures (see Figs 1 and 4).17 From a peri-
different treatment methods and/or various tech- odontal point of view, it seems indeed conceivable that

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in these cases the organism will be able to restore the cion of proximal caries (see Fig 1),49 severe cavity forma-
biologic width (without the need of surgical interven- tion was obvious from the CBCT scans (compare Figs 2b
tion or orthodontic extrusion), or will adapt to the new and 3a), thus highlighting the increased sensitivity of
one.47 This has been corroborated by a recent study this imaging technology,52 and elucidating the ability to
revealing that adhesive fragment reattachment using additionally provide valuable information that helps
composite resins did not affect periodontal health.48 with diagnosis and treatment decision.
With regard to the etiology of gingivitis, it is well- The clinical application of the PBE technique
known that the latter is caused by a chronic biofilm-as- described in the present case report was performed
sociated (non-specific) inflammation caused by a poly- using a three-step etch-and-rinse adhesive system
microbial infection; there is a clear correlation between (Syntac, Ivoclar Vivadent) mediating a physically stable
microbial deposits and papillary inflammation. How- bond between dentin and composite resin (G-ænial
ever, this not only is a matter of (daily) oral hygiene, but Universal Flo and G-ænial, GC, as well as Heliobond and
refers also to site-specific niches of iatrogenic origin (ie, Variolink, Ivoclar Vivadent). This was followed with an
overhangs and excess of restorative materials); addi- indirect CAD/CAM leucite-based glass-ceramic restor-
tionally (but not always taken into account), caries ation (IPS Empress CAD, Ivoclar Vivadent). The decision
lesions are obstacles to effective oral hygiene, in partic- to perform a PBE was based on the deep location of the
ular with respect to the clinically invisible approximal carious defect and the concomitant difficulties achiev-
lesions in teenagers or young adults (see Fig 1).49 While ing an adequate isolation for digital impression and
the occurrence of plaque does not have a comparable adhesive cementation of the secondary restoration. It is
predictive power, bleeding on probing helps with the known that using an appropriate pre-conditioning
treatment decision, indicating that there is lesion prog- technique will result in reliable bond strengths
ress49 or cavitation50 (with the latter unambiguously between composite resin (bases or build-ups) and
being a plaque retention site; see Fig 2), and suggest- ceramics.53 From a clinical perspective, this regimen
ing to initiate operative treatment. was justified from several papers confirming the posi-
With regard to diagnostics, initial and even moder- tive prognosis of this kind of treatment.9,13,16,20,34
ate stages of approximal caries often are not detectable Indirect treatment of posterior proximal cavities
at the clinical level. Thus, bitewing radiographs are revealing extensions below the CEJ is clinically ambi-
considered an essential prerequisite facilitating treat- tious, due to difficulties in achieving an adequate mois-
ment decision; it is commonly accepted that once the ture control.13 When encountering such clinical situa-
caries lesion extends radiographically into (outer) den- tions it is a considerable option to relocate the proximal
tin, a loss of surface integrity is most likely to occur.50 box floor, using a composite resin in order to facilitate
Concomitantly, this surface breakdown will provide rubber dam application and adhesive luting proced-
retention sites for dental biofilm accumulation, empha- ures (see Fig 3h), in particular if several adjacent cavities
sizing the need for an inescapable therapeutic inter- have to be treated.13 PBE additionally ensures further
vention.51 Based on these requirements, the extent of requirements like eliminating undercuts and allows
the caries lesion on the left second maxillary molar into proximally undermining caries to be restored minimally
dentin was obvious from the initial bitewing radio- invasively to limit the size of the prepared cavities for
graph; however, this radiograph did not demonstrate a indirect restorations, thus preventing extensive sub-
communication between the tooth’s lesion and the oral stance loss,18 improving cuspal reinforcement,11 and
cavity, since no surface damage was apparent (see compensating for limited polymerization with deep
Fig 2a), thus corroborating previous reports of low cav- defects. It should be emphasized that composite resin
itation detection rates.50 Nonetheless, corresponding to restorations do not serve only for their inherent
the papillary inflammation and the entertained suspi- esthetic qualities; instead, conservative cavity prepar-

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ations with traditional configurations (as used for amal- no saliva or blood contamination will impede the out-
gam in the past) are not considered mandatory any- come of the digital impression.
more; thus, sound tooth substance can be preserved, Since most adhesive cements are photopolymer-
and this is an undisputable advantage of direct com- ized, sufficient light-curing through the secondary
posite fillings. (indirect) restoration is crucial for clinical success. How-
Due to the nature of a deep proximal box, air-drying ever, when facing a deep proximal box, sufficient
procedures often are not efficient, and pooling of water light-curing of luting composites or bonding agents via
or adhesive in the cavity corners frequently occurs. the secondary restoration might be less efficient. Con-
Such ineffective drying and pooling effects have been sequently, sufficient polymerization is impeded when
shown to impair adequate removal of solvent and encountering a deep proximal box. With these situa-
water, subsequently decreasing the strengths of adhe- tions, PBE might be an alternative to solve this complex
sive bonding which is the basis for a successful restor- of problems.
ation in the long term.54 To prevent such pooling
effects, PBE seems to be an adequate option, in partic-
ular if combined with sophisticated modifications of
CONCLUSIONS
application techniques (eg, the “snow plough tech- From a clinical point of view, the PBE technique (in
nique”).17 combination with an indirect CAD/CAM restoration)
A further advantage of the PBE technique is the undoubtedly has several advantages:
immediate dentin sealing (IDS) which is performed • IDS will increase the physical performance of the
concomitantly with the PBE procedure. In case a signif- adhesively luted base
icant area of dentin is exposed during the preparation • microbial invasion and postoperative pain will be
for an indirect restoration, evidence supports the appli- avoided
cation of an adhesive resin coating to the freshly cut • oral fluid control will be facilitated
and conditioned dentin, thus creating a collagen fibril • quality of digital (or analog) impressions will be
reinforced complex interphase. This procedure includes improved
advantages like increased retention, reduced marginal • design of proximal contact will be enabled
leakage, improved bond strengths, and decreased post- • overall time spent with adhesively bonded compos-
operative sensitivity.55 Thus, the sealed dentin is pro- ite resin or indirect restorations will be shortened.
tected from bacterial invasion during the provisional
phase, and the luting procedure of any definite porce- Given an adequate isolation technique, the use of
lain restoration requires less or no anesthetics at all. appropriate materials, and careful handling of the lat-
An optimal digital impression is fundamental to any ter, PBE is considered a promising restorative comple-
CAD/CAM restoration, since image quality, accuracy, tion to facilitate treatment of advanced caries lesions
and precision of the acquired image is equivalent to with dentin/cementum margins located beneath the
the precision of the final outcome. However, digital gingival tissues.
impressions of deep cavities in the molar region can be Currently, valid knowledge of PBE is primarily based
challenging due to the limited space available and the on laboratory studies; notwithstanding, PBE using flow-
restrictions of the used digital system’s scanning able composite resins seems to be a viable and reason-
depths. By elevating the proximal box, a digital scanner able treatment option, representing a valuable addition
can provide more accurate results if compared to deep to the dental clinician’s armamentarium. With regard to
cavities. Furthermore, the scanning procedure is much possible implications for research, the moderate num-
easier to handle and will be accelerated. With an ade- ber of clinical trials highlights the field of major interest.
quate isolation the overall result will be satisfying, since Therefore, more high-quality research (reasonably cov-

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Kielbassa/Philipp

ering both cariologic and periodontal aspects, and 19. Zaruba M, Gohring TN, Wegehaupt FJ, Attin T. Influence of a proximal margin
elevation technique on marginal adaptation of ceramic inlays. Acta Odontol
focusing on the clinical durability of PBE as a two-step Scand 2013;71:317–324.
restoration technique) is warranted. 20. Marchesi G, Spreafico R, Frassetto A, et al. Cervical margin-relocation of CAD/
CAM lithium disilicate ceramic crown using resin-composite. Dent Mater
2014;30(Suppl 1):e14.
21. Da Silva Goncalves D, Cura M, Fuentes MV, Gomes G, Ceballos L. Influence of
coronal gingival margin relocation and the luting cement in composite inlays
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