February 22, 2024 • 25 mins
Why aren’t all dentists performing deep margin elevations with composite? It might be because you’re listening to old research. “Violating the biologic width” was disproven in 2014. Gingival tissue doesn't have an adverse reaction to the material, it has an adverse reaction to the biofilm under a retention crown or poorly bonded restoration. If you have experienced failures with glass ionomers, use composite instead. In 2019, 12-year clinical evaluations showed the success of composite, a material that better mimics a natural tooth compared to brittle glass ionomers. Understanding how to perform deep margin elevations is an essential tool for dentists wanting to save more teeth.
Article referenced in this episode:
- Dietschi D, Spreafico R. Current clinical concepts for adhesive cementation of tooth-colored posterior restorations. Pract Periodont Aesthet Dent 1998;10(1):47-5,
- Dietschi D, Et al. In vitro evaluation of marginal and internal adaptation after occlusal stressing of indirect class II composite restorations with different resinous bases. Ea J Oral Sci. 2003(111):73-80
- Magne P, Spreafico R. Deep margin elevation: a paradigm shift. Am J Esth Dent. 2012(2)86-96.
- 2014 proximal box elevation with resin composite and the dogma of biological width clinical r2-techinique and critical review
- Bresser RA, Et al. Up to 12 years clinical evaluation of 197 partial indirect restorations with deep margin elevation in the posterior region. J Dent. 2019.
- Dietschi, Spreafico. Adhesive Metal-Free Restorations. Quintessence Books; 1997.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:40):
Well, welcome to episode seven.
We have some informationthat you're all going
to find very interestingand very practical.
And it's a follow up on episode sixwhere we talked about the stress
reduced approach that SimoneDeliperi first published in 2002,
and we wrote some articles2009, other articles that we've written.
(01:04):
But the stress reduced direct techniqueis a part of every biomimetic restoration.
Whether you construct the whole toothas Simone does often,
or you take the foundationand stress, reduce it for your bio base,
the stress reduceddirect technique is part of that.
(01:25):
Now we're going to talk about the otherstress reducing technique in a bio base
that is criticalbesides the composite incremental
technique that Simone published.
And this is called deep margin elevation.
(01:47):
Now a deep marginelevation is a stress reducing technique.
Why is that?
It's because these deep areashave to be built up separately
from the rest of the missing dentin.
And that separate build up takes timeand so on.
(02:07):
We have a deep margin elevation.
It's taking time.
In that timeallows the bond to the dentin,
the time to mature and to timeto flow towards the hybrid layer
and that maturation is what we calldecoupling with time.
So stress reducing direct techniquefor mobile base
(02:28):
that includes deep margin elevation.
These are protocols that allow us to havethe highest bond strength
in our getting replacement.
So the articlesthat we will be talking about today
will be 1998 Didier DietschiRoberto Sprefico, the first published
(02:51):
illustration of a deep margin elevation.
After that, two other papers from Dietschithat followed up in his Ph.D.
research.
And those two papers investigatedwhat kind of materials
should be usedfor the deep margin elevation.
And that was published in 2003.
(03:13):
Also, in 2003, we had a paperthat showed that a separation
of the deepest part of a classto should be separated by time
to have the best resultsin a class two restoration.
So a deep box and a classtwo restoration are very similar,
(03:35):
except ones deep ones not as deep,but both were shown by Dietschi
to have a benefitwith these stress reducing protocols.
And then we have independentconfirmation from three countries
actually,when they talk about the deep margin
elevation 2012,Pascal Magne and Roberto Spreafico
(03:56):
specifically published that article.
And then in 2014, a German group didthe same long term in vivo study in vitro
and in vivo studies compared.
And then in 2019 we had a long term12 year study from David Gerdole
(04:17):
and his associates in Franceand in Holland,
particularly Marco Gresnigtin following these deep margin elevations.
Long term.
So let's talk about how did I first domy first deep margin elevation?
Well, it has the history in thatwith traditional dentistry,
I was doing a lot of root canals.
(04:39):
And so with root canalsthat had been caused from leakage
and decay around deep classtwo restorations,
I had the opportunity to learnhow to be a better and at honest,
and I took advantage of thatand that was from courses
given by my class valedictorianat University Pacific, Steve Buchanan.
(05:03):
Steve Buchanan had revolutionizedthe anatomic world when he started
to embrace mechanical rotary instruments,nickel titanium files,
and he became very popular speaker.
And I went to many of his lecturesat ADA convention,
and then I did a hands on course with himand that hands on courses in 1999.
(05:24):
And that was the first timeI was introduced to a microscope.
And then I bought my microscopeat the end of that year.
But then in these timeswhen I was becoming
a very proficient endodontist,I would do my own endo.
And then after I had done that,then I would restore the tooth.
But the situation in endodonticsis that you must isolate the tooth
(05:49):
to prevent bleach,which is the irrigating solution
from going into the patient's mouth,which is never a good
if the patient is having the bleachput into there into their oral cavity.
So what I'm doing my endo,if I have a deep sub marginal defect
that I'm trying to isolate,that's a problem.
(06:12):
Traditional techniques would say, well,you could go
and do a crown lengthening surgery.
I knew how to do that and I could do that.
But then there's a healing time.
But the idea came to mewhen I was getting ready to do a molar
and at our treatment that if I built upthe deep sub gingival wall with composite,
(06:33):
which had been, you know, started trainingtwo years before with Ray Bertolotti.
then I could isolate the toothwith the rubber dam easily
and there would not be a problemwith bleach contamination.
So I did my first deep marginelevation, 1998, early 1998,
and I did it with the chemical curematerials that I had chemical your bonding
(06:58):
system, photo bond and the dualcure material that it was called
the best field to be madeby Ray Bertolotti from Biscoe.
And this techniquethat I use to elevate this margin
once it was bonded, allowed me to isolateand do my ended on a treatment,
(07:19):
but then my ended on a treatment was done.
And I'm looking at this bonded boxthat I had full confidence in,
even though in 1998I didn't have all the details
of hierarchy of Bondabilityand dental flow
with chemical cure compositesthat we talked about last episode.
(07:41):
But I did know thatthe C factor was very low why?
because I actually could see the bondedsurface
is just the shell of the boxbonded on two thin
sides of the mesial and buccaland one box depth.
But then the on bonded surfaceof that wall
(08:02):
that was being built to isolate tooththat had a huge unbonded ratio.
It was very, very low.
Therefore the shrinkage of the compositewould not stress the bond very much.
It would shrink not away from a wall,but towards the center of mass.
You know, theI could make an illustration of that.
(08:22):
It's a little bit complicated if youhaven't been trained in the six lessons.
But still, the idea is that I elevateda deep margin 3 to 4 millimeters
with chemical pure composite.
I used a dual curebonding system photo bond,
and then once I had thatdone, allowed me to do the handle.
(08:44):
And then the questionwas traditional techniques.
In 1998, I'm still going between crowns.
No crowns, crowns, no crowns.
So I felt comfortable in large composite.
ObviouslyI've been doing crowns successfully
for 18 years, butI looked at their restoration
and I'm sayingI'm not going to take that off
(09:07):
so that I can create a perfect ferruleA ferrule by definition is two millimeters
of sound to structurethat is going to give the firm foundation
that the Crown is going to attach to,but that ferrule was going to be
two millimeters sub gingival.
(09:27):
And so I had to deal with the gingiva,which would be a surgical procedure
or if I have the bonded deep marginand it sealed
and I'm not relyingon mechanical retention which a Farrell
is part of in a Crown retention, butI'm just going to be relying on adhesive
compliant planning in this situationto do a large inlay actually.
(09:53):
And so at that point I said, look,the rest of my tooth,
the bond to dentin has beenestablished was actually established
24 hours ago.
I had finished the Endo patient came backactually the next day
and I had this bonded surfaceand I said, I'm
just going to add to that surface.
(10:14):
So the immediate dentinsealing is in place.
There's been no stress on the dentinbond of all of the dental surface
around the rootcanal, access to the pulp chamber.
I didn't edge,but I knew that the composite,
the immediate end ceilingshould be cleaned a little bit.
And so that surface was rinsedried that point.
(10:37):
I'm not sure if I had air abrasion,but I added another layer of adhesive
on to my immediate and ceiling.
And then I looked at my preparationthat was immediate
and sealed and then the deepmargin was elevated in the back.
And then I said, Well,there's some undercuts here.
I can change the geometryby taking out those undercuts
(11:00):
by adding composite bonded composite.
So I changed the geometry of the largeinlay shape
preparation by one doing the deepmargin elevation separately
and then removing any undercutsby an additive technique.
And all of a sudden I had a nice, smoothand flat on the bottom
and smooth on the side inlay preparationthat had composite on the gingival floor
(11:24):
that it had been elevatedand then composite on the buckle
and lingual walls.
And I had nowa nice inlay preparation that had draw
and I took that impressionand made my inlay my large inlay.
And then cemented itwith protocols of a resin cement.
(11:45):
And after that was done in 1998,I looked at it and I said,
Well, I wonder if anybodyelse in the world is doing this.
And, you know,I was determined to find out.
So 1998,I went to the ADA convention and May,
had lunch with Bortolottiand met Gary Unterbrink for the first time
(12:09):
and heard John Cank and Charlie Coxheard the name John Kois.
I mean, 1998 was that year for me.
That really got me into a commitmentof learning
as much as I can about adhesive dentistry.
But in 1998,the published book from Dietschi
was this book, and I purchasedthat at the convention 1998.
(12:33):
It did not have deep margin elevationin that book, but
I had the opportunity to talk with GaryUnterbrink, talk with Ray Bertolotti.
They didn't see any any problemwith having a resin base
underneath the composite restorations,just making it larger.
But the separationof these two masses of composite
(12:55):
the inlay and the resonance baseto me was now becoming
clear that the key factordetermined portion of my deep
marginal elevationthat I had made was the correct one.
Again, I didn't have decoupling with timeand hierarchy bondability in 1998
fully in my mind.
(13:17):
But as I saw this restoration go onfor the next few years, I visited
Didier Dietschi as I took a coursetwo day course at UCLA in the year 2000.
I wanted to see if he had figured outthis deep margin situation
he had, but he had not figured outthe hierarchy of bond ability
(13:40):
and the decoupling with time.
But stillwe talked about marginally elevated.
Yeah, I just published a papercoming out this year
and that paper will show thatfor the first time and this is the paper
and it's a paperthat the title had nothing to do with.
The marginalization sayscurrent clinical concepts for adhesive
segmentation of tooth colored posteriorrestorations is the first time
(14:03):
that heated compositeis used to see these inlays launches.
But in that articlethere was a very small illustration,
and this small illustrationhad immediate debt and ceiling
and a deep margin elevation,not a very deep one,
but it was definitely a situationwhere the bio base is created
(14:27):
first by a base that was wasn'tnamed until 2003.
It's now in Magne Belser’s book,but Wendell
Robertson came up with the bio based term,I have popularized it.
But that paper in 98was part of Dietcshi’s investigation
that he was carrying on,and eventually he got a Ph.D.
(14:48):
dissertation, and that dissertationpublication contained two articles
that had been publishedin a kind of an obscure
journal for Americans,European Journal of Oral Sciences,
but that these two papersgave the information
that the composite should be usedfor this deep margin elevation.
(15:10):
Composite had characteristicsthat were more tooth like didn't
use the term biometric,but that's what he meant.
And then as the years went on,I came to in 2005 to visit Pascal Magne
to see what he knew and see whathe was doing and what his plans were.
Because I've been teaching the six lessonsfor two years
(15:33):
and the first case that I showed himwas that the deep margin elevation
that I did in 1998,so this is at USC in 2005,
this restoration is now seven years old.
And I showed it to Pascaland he said, Nobody's published that yet.
And I said, I know.
I've been looking at the literatureand talk with Dietschi
(15:55):
He hasn't published the case,but he had an illustration that he said
was going to be in the new article.
And at 2005then I did have access to that article.
But anyway, the idea was that in Genevathey were doing this.
I had been doing thismy office, 1998 was the year
that we both figured this outindependently.
(16:17):
We fast forward as we keep practicingdentistry and doing dentistry, and I'm
teaching dentistry now to dentists,practicing
dentists in 2003 and the dissertationfrom Dietschi is published,
I get a copy of it from Pascal.
He had a copy in his office.
I borrowed it and made a copy ofactually made three copies,
gave one to Simone Deliperi and that Ph.D.
(16:40):
dissertationis an outstanding piece of work.
I thanked Dietschi for this.
Last year.
When I spoke with him,Davey and I were on the same stage,
the same conference in Chile,but you know, working these concepts out
until it becomes taught and then practicedand then monitored long term,
(17:02):
that's a more difficult thing to do.
The first paper published by Pascal Magneand Roberto Spreafico,
he actually said that this deep marginelevation was a paradigm shift.
Obviously, it's something that,you know, bonding or restoration
to a composite base, peoplethat don't know composite chemistry
and don't know thethe difficulties of it
(17:26):
and are very afraid to do that.
But to those of us who became massesof adhesive dentistry early on,
we understood that this had the ability toconnect with the two side to side front.
The back and top the bottomin that 30 plus megapascal range.
And this has been proven that's science.
(17:49):
But then to get enough people to do itand follow it,
there's two important papersthat were published,
the one out of Germanyand the title was Proximal Black
Box Elevation with resinComposite and the dogma of biologic width
(18:11):
clinical are two techniqueand critical review.
They called it the R two technique.
They should have called itthe deep margin elevation two years before
Magne Spreafico were the first onesto put that term in to publication.
There had been a USC manualin 2006 that included that.
(18:31):
But you know,that's kind of splitting hairs.
But the Germans, what they wanted toinvestigate
is why these sub gingival compositeswere not bleeding
because the myth or the dogma of biologicwith the violation
that every periodontist and presidentis working in, in conjunction
felt like it was a reaction of the tissueto the Crown material
(18:55):
where in reality it was a reactionto the biofilm underneath the crowns
that were not bondedand did not stop this gap formation
underneath crowns and fillings.
So inflammation of gingival of an amalgamor inflammation of gingival of a composite
or inflammation of gingival of a crownis actually related not to the material
(19:19):
but to the bacteria that are underneaththe crown or the filling.
And so that'swhat causes the inflammation.
If you stay bonded in these deepmargin elevations,
then that inflammation goes away.
This paper byBresser and Gerdolle, Heijkant,
Pouwel, Cune and Marco Gresnigtmy good friend
(19:42):
at Groingen University in Holland,their papers showed 95% no inflammation
on any of these deep marginal nations.
Some of these been followed12 years published in 2019.
And so my cases are more than 20 years oldand the same situation
is they stay bonded.
There's no inflammation, there'sno biofilm
(20:03):
underneath the crown or the restoration.
And so the biologic reaction,the inflammatory reaction of the gingiva
to these bacteria is what's calledwhat causes this inflammation.
And often associated with bleeding,as the inflammation is into the connective
tissue portion of the gingival attachment.
(20:26):
Wow. So that'show deep marginalization has got going.
And they're possible with composite.
They're not possible long term withresin modify, glass, monomers and glass
enemas.
It's a little discouragingwhen I hear training that
(20:46):
some of the top dental schoolswhere they're actually still doing
deep marginalizationwith glass eye armor, that's also called
an open sandwich technique.
That technique was thoroughly debunkedin the late eighties
because the glass monomerswere brittle under functional stresses
they would break down in the years 4 to 6,there are no 20 year
(21:09):
deep margin elevations using glass.
I honor the successful cases,but it's still being taught
in the couple of dental schools aroundwhich it wasn't being taught it.
It'll be good for four or five years,but then you have to redo it
because it breaks down underneathyour composite only in layer restoration.
And that comes from solid science.
(21:31):
The Ph.D. work of Dietschi.
Consider himone of my early mentors, of course,
Ray Bertolotti and Gray Unterbrink.
Didier Dietschi I was veryimpressed with everything
that he was doing as far as minimallyinvasive and adhesive dentistry.
Of course,esthetically just totally beautiful,
(21:51):
and after the course it was actually underthe direction of Ed McLaren at UCLA.
He was teaching a cosmetic dentistrymaster course at UCLA at that time.
But the and Ed McLaren and I were talking,I said,
I think you're the best dentist the world,but who do you think
is the best dentist?
And he without hardly even thinking, saidUrs Belser,
(22:14):
because I hadn't heard his name.
I had read it, but not remembered it.
You wrote part of the introductionto Dietschi’s Book, and Urs
Belser was the mentor of Didier Dietschiand the mentor of Pascal Magne.
And Belser was is a presidentwho mastered all areas of prosthodontics
(22:34):
and all areas of implant dentistryassociated with prosthodontics
and Belser’s a top researcher, teacher,the administrator,
just a great human being from all reports.
I haven't met him personally, but Belserbasically told Dietschi if adhesive
dentistry lives up to his potential,it will eliminate most of the endo.
(22:55):
It will eliminate most of the perio,it will eliminate
prosthodontic destructionof tooth structure.
And so all of the specialty disciplines,including implants,
will be majorly impactedby implementing adhesive dentistry.
Now, if you're a specialist,you might not like to hear that message.
(23:17):
I know when I told Steve Buchananabout the six lessons
21 years ago, he had lunch.
I said, Steve,this is going to prevent a lot of endo.
And he looked at his says, Great, He'svery busy in Santa Barbara.
Still is.
He's still teaching and practicing,I believe in Santa Barbara,
but he changed the world of endodonticsThe world paradigm has changed.
(23:40):
Unfortunately,it's mostly based on extracting teeth
that could be savedwith the periodontal treatments
and good restorative treatmentslike biomimetic dentistry.
But these evolutions Belser was forhe felt like it was progress.
As long as we're conserving to structureand conserving pulp
(24:01):
tissue, Belser understood the differencebetween a vital and a non vital tooth
and all of the investigationssince the early 2000s of reinforce
the idea that a brittlenesscomes from antibiotic treatment
that cannot be remedied.
A tooth that has enteredour treatment has three times
(24:22):
the potential to fracturebecause it's three times as brittle
and it's only a third of the engineeringterm as toughness.
So a toughtooth, tough material flexes
a brittle tooth.
Their brittle material beginsto fracture through crack
initiation, crack propagation,and finally catastrophic failure.
(24:46):
Anyway, the lot to think about.
But here we are change the world.
They'll next time get bonded. They bonded.
Well, welcome to episode seven.
We have some informationthat you're all going
to find very interestingand very practical.
And it's a follow up on episode sixwhere we talked about the stress
reduced approach that SimoneDeliperi first published in 2002,
and we wrote some articles2009, other articles that we've written.
(01:04):
But the stress reduced direct techniqueis a part of every biomimetic restoration.
Whether you construct the whole toothas Simone does often,
or you take the foundationand stress, reduce it for your bio base,
the stress reduceddirect technique is part of that.
(01:25):
Now we're going to talk about the otherstress reducing technique in a bio base
that is criticalbesides the composite incremental
technique that Simone published.
And this is called deep margin elevation.
(01:47):
Now a deep marginelevation is a stress reducing technique.
Why is that?
It's because these deep areashave to be built up separately
from the rest of the missing dentin.
And that separate build up takes timeand so on.
(02:07):
We have a deep margin elevation.
It's taking time.
In that timeallows the bond to the dentin,
the time to mature and to timeto flow towards the hybrid layer
and that maturation is what we calldecoupling with time.
So stress reducing direct techniquefor mobile base
(02:28):
that includes deep margin elevation.
These are protocols that allow us to havethe highest bond strength
in our getting replacement.
So the articlesthat we will be talking about today
will be 1998 Didier DietschiRoberto Sprefico, the first published
(02:51):
illustration of a deep margin elevation.
After that, two other papers from Dietschithat followed up in his Ph.D.
research.
And those two papers investigatedwhat kind of materials
should be usedfor the deep margin elevation.
And that was published in 2003.
(03:13):
Also, in 2003, we had a paperthat showed that a separation
of the deepest part of a classto should be separated by time
to have the best resultsin a class two restoration.
So a deep box and a classtwo restoration are very similar,
(03:35):
except ones deep ones not as deep,but both were shown by Dietschi
to have a benefitwith these stress reducing protocols.
And then we have independentconfirmation from three countries
actually,when they talk about the deep margin
elevation 2012,Pascal Magne and Roberto Spreafico
(03:56):
specifically published that article.
And then in 2014, a German group didthe same long term in vivo study in vitro
and in vivo studies compared.
And then in 2019 we had a long term12 year study from David Gerdole
(04:17):
and his associates in Franceand in Holland,
particularly Marco Gresnigtin following these deep margin elevations.
Long term.
So let's talk about how did I first domy first deep margin elevation?
Well, it has the history in thatwith traditional dentistry,
I was doing a lot of root canals.
(04:39):
And so with root canalsthat had been caused from leakage
and decay around deep classtwo restorations,
I had the opportunity to learnhow to be a better and at honest,
and I took advantage of thatand that was from courses
given by my class valedictorianat University Pacific, Steve Buchanan.
(05:03):
Steve Buchanan had revolutionizedthe anatomic world when he started
to embrace mechanical rotary instruments,nickel titanium files,
and he became very popular speaker.
And I went to many of his lecturesat ADA convention,
and then I did a hands on course with himand that hands on courses in 1999.
(05:24):
And that was the first timeI was introduced to a microscope.
And then I bought my microscopeat the end of that year.
But then in these timeswhen I was becoming
a very proficient endodontist,I would do my own endo.
And then after I had done that,then I would restore the tooth.
But the situation in endodonticsis that you must isolate the tooth
(05:49):
to prevent bleach,which is the irrigating solution
from going into the patient's mouth,which is never a good
if the patient is having the bleachput into there into their oral cavity.
So what I'm doing my endo,if I have a deep sub marginal defect
that I'm trying to isolate,that's a problem.
(06:12):
Traditional techniques would say, well,you could go
and do a crown lengthening surgery.
I knew how to do that and I could do that.
But then there's a healing time.
But the idea came to mewhen I was getting ready to do a molar
and at our treatment that if I built upthe deep sub gingival wall with composite,
(06:33):
which had been, you know, started trainingtwo years before with Ray Bertolotti.
then I could isolate the toothwith the rubber dam easily
and there would not be a problemwith bleach contamination.
So I did my first deep marginelevation, 1998, early 1998,
and I did it with the chemical curematerials that I had chemical your bonding
(06:58):
system, photo bond and the dualcure material that it was called
the best field to be madeby Ray Bertolotti from Biscoe.
And this techniquethat I use to elevate this margin
once it was bonded, allowed me to isolateand do my ended on a treatment,
(07:19):
but then my ended on a treatment was done.
And I'm looking at this bonded boxthat I had full confidence in,
even though in 1998I didn't have all the details
of hierarchy of Bondabilityand dental flow
with chemical cure compositesthat we talked about last episode.
(07:41):
But I did know thatthe C factor was very low why?
because I actually could see the bondedsurface
is just the shell of the boxbonded on two thin
sides of the mesial and buccaland one box depth.
But then the on bonded surfaceof that wall
(08:02):
that was being built to isolate tooththat had a huge unbonded ratio.
It was very, very low.
Therefore the shrinkage of the compositewould not stress the bond very much.
It would shrink not away from a wall,but towards the center of mass.
You know, theI could make an illustration of that.
(08:22):
It's a little bit complicated if youhaven't been trained in the six lessons.
But still, the idea is that I elevateda deep margin 3 to 4 millimeters
with chemical pure composite.
I used a dual curebonding system photo bond,
and then once I had thatdone, allowed me to do the handle.
(08:44):
And then the questionwas traditional techniques.
In 1998, I'm still going between crowns.
No crowns, crowns, no crowns.
So I felt comfortable in large composite.
ObviouslyI've been doing crowns successfully
for 18 years, butI looked at their restoration
and I'm sayingI'm not going to take that off
(09:07):
so that I can create a perfect ferruleA ferrule by definition is two millimeters
of sound to structurethat is going to give the firm foundation
that the Crown is going to attach to,but that ferrule was going to be
two millimeters sub gingival.
(09:27):
And so I had to deal with the gingiva,which would be a surgical procedure
or if I have the bonded deep marginand it sealed
and I'm not relyingon mechanical retention which a Farrell
is part of in a Crown retention, butI'm just going to be relying on adhesive
compliant planning in this situationto do a large inlay actually.
(09:53):
And so at that point I said, look,the rest of my tooth,
the bond to dentin has beenestablished was actually established
24 hours ago.
I had finished the Endo patient came backactually the next day
and I had this bonded surfaceand I said, I'm
just going to add to that surface.
(10:14):
So the immediate dentinsealing is in place.
There's been no stress on the dentinbond of all of the dental surface
around the rootcanal, access to the pulp chamber.
I didn't edge,but I knew that the composite,
the immediate end ceilingshould be cleaned a little bit.
And so that surface was rinsedried that point.
(10:37):
I'm not sure if I had air abrasion,but I added another layer of adhesive
on to my immediate and ceiling.
And then I looked at my preparationthat was immediate
and sealed and then the deepmargin was elevated in the back.
And then I said, Well,there's some undercuts here.
I can change the geometryby taking out those undercuts
(11:00):
by adding composite bonded composite.
So I changed the geometry of the largeinlay shape
preparation by one doing the deepmargin elevation separately
and then removing any undercutsby an additive technique.
And all of a sudden I had a nice, smoothand flat on the bottom
and smooth on the side inlay preparationthat had composite on the gingival floor
(11:24):
that it had been elevatedand then composite on the buckle
and lingual walls.
And I had nowa nice inlay preparation that had draw
and I took that impressionand made my inlay my large inlay.
And then cemented itwith protocols of a resin cement.
(11:45):
And after that was done in 1998,I looked at it and I said,
Well, I wonder if anybodyelse in the world is doing this.
And, you know,I was determined to find out.
So 1998,I went to the ADA convention and May,
had lunch with Bortolottiand met Gary Unterbrink for the first time
(12:09):
and heard John Cank and Charlie Coxheard the name John Kois.
I mean, 1998 was that year for me.
That really got me into a commitmentof learning
as much as I can about adhesive dentistry.
But in 1998,the published book from Dietschi
was this book, and I purchasedthat at the convention 1998.
(12:33):
It did not have deep margin elevationin that book, but
I had the opportunity to talk with GaryUnterbrink, talk with Ray Bertolotti.
They didn't see any any problemwith having a resin base
underneath the composite restorations,just making it larger.
But the separationof these two masses of composite
(12:55):
the inlay and the resonance baseto me was now becoming
clear that the key factordetermined portion of my deep
marginal elevationthat I had made was the correct one.
Again, I didn't have decoupling with timeand hierarchy bondability in 1998
fully in my mind.
(13:17):
But as I saw this restoration go onfor the next few years, I visited
Didier Dietschi as I took a coursetwo day course at UCLA in the year 2000.
I wanted to see if he had figured outthis deep margin situation
he had, but he had not figured outthe hierarchy of bond ability
(13:40):
and the decoupling with time.
But stillwe talked about marginally elevated.
Yeah, I just published a papercoming out this year
and that paper will show thatfor the first time and this is the paper
and it's a paperthat the title had nothing to do with.
The marginalization sayscurrent clinical concepts for adhesive
segmentation of tooth colored posteriorrestorations is the first time
(14:03):
that heated compositeis used to see these inlays launches.
But in that articlethere was a very small illustration,
and this small illustrationhad immediate debt and ceiling
and a deep margin elevation,not a very deep one,
but it was definitely a situationwhere the bio base is created
(14:27):
first by a base that was wasn'tnamed until 2003.
It's now in Magne Belser’s book,but Wendell
Robertson came up with the bio based term,I have popularized it.
But that paper in 98was part of Dietcshi’s investigation
that he was carrying on,and eventually he got a Ph.D.
(14:48):
dissertation, and that dissertationpublication contained two articles
that had been publishedin a kind of an obscure
journal for Americans,European Journal of Oral Sciences,
but that these two papersgave the information
that the composite should be usedfor this deep margin elevation.
(15:10):
Composite had characteristicsthat were more tooth like didn't
use the term biometric,but that's what he meant.
And then as the years went on,I came to in 2005 to visit Pascal Magne
to see what he knew and see whathe was doing and what his plans were.
Because I've been teaching the six lessonsfor two years
(15:33):
and the first case that I showed himwas that the deep margin elevation
that I did in 1998,so this is at USC in 2005,
this restoration is now seven years old.
And I showed it to Pascaland he said, Nobody's published that yet.
And I said, I know.
I've been looking at the literatureand talk with Dietschi
(15:55):
He hasn't published the case,but he had an illustration that he said
was going to be in the new article.
And at 2005then I did have access to that article.
But anyway, the idea was that in Genevathey were doing this.
I had been doing thismy office, 1998 was the year
that we both figured this outindependently.
(16:17):
We fast forward as we keep practicingdentistry and doing dentistry, and I'm
teaching dentistry now to dentists,practicing
dentists in 2003 and the dissertationfrom Dietschi is published,
I get a copy of it from Pascal.
He had a copy in his office.
I borrowed it and made a copy ofactually made three copies,
gave one to Simone Deliperi and that Ph.D.
(16:40):
dissertationis an outstanding piece of work.
I thanked Dietschi for this.
Last year.
When I spoke with him,Davey and I were on the same stage,
the same conference in Chile,but you know, working these concepts out
until it becomes taught and then practicedand then monitored long term,
(17:02):
that's a more difficult thing to do.
The first paper published by Pascal Magneand Roberto Spreafico,
he actually said that this deep marginelevation was a paradigm shift.
Obviously, it's something that,you know, bonding or restoration
to a composite base, peoplethat don't know composite chemistry
and don't know thethe difficulties of it
(17:26):
and are very afraid to do that.
But to those of us who became massesof adhesive dentistry early on,
we understood that this had the ability toconnect with the two side to side front.
The back and top the bottomin that 30 plus megapascal range.
And this has been proven that's science.
(17:49):
But then to get enough people to do itand follow it,
there's two important papersthat were published,
the one out of Germanyand the title was Proximal Black
Box Elevation with resinComposite and the dogma of biologic width
(18:11):
clinical are two techniqueand critical review.
They called it the R two technique.
They should have called itthe deep margin elevation two years before
Magne Spreafico were the first onesto put that term in to publication.
There had been a USC manualin 2006 that included that.
(18:31):
But you know,that's kind of splitting hairs.
But the Germans, what they wanted toinvestigate
is why these sub gingival compositeswere not bleeding
because the myth or the dogma of biologicwith the violation
that every periodontist and presidentis working in, in conjunction
felt like it was a reaction of the tissueto the Crown material
(18:55):
where in reality it was a reactionto the biofilm underneath the crowns
that were not bondedand did not stop this gap formation
underneath crowns and fillings.
So inflammation of gingival of an amalgamor inflammation of gingival of a composite
or inflammation of gingival of a crownis actually related not to the material
(19:19):
but to the bacteria that are underneaththe crown or the filling.
And so that'swhat causes the inflammation.
If you stay bonded in these deepmargin elevations,
then that inflammation goes away.
This paper byBresser and Gerdolle, Heijkant,
Pouwel, Cune and Marco Gresnigtmy good friend
(19:42):
at Groingen University in Holland,their papers showed 95% no inflammation
on any of these deep marginal nations.
Some of these been followed12 years published in 2019.
And so my cases are more than 20 years oldand the same situation
is they stay bonded.
There's no inflammation, there'sno biofilm
(20:03):
underneath the crown or the restoration.
And so the biologic reaction,the inflammatory reaction of the gingiva
to these bacteria is what's calledwhat causes this inflammation.
And often associated with bleeding,as the inflammation is into the connective
tissue portion of the gingival attachment.
(20:26):
Wow. So that'show deep marginalization has got going.
And they're possible with composite.
They're not possible long term withresin modify, glass, monomers and glass
enemas.
It's a little discouragingwhen I hear training that
(20:46):
some of the top dental schoolswhere they're actually still doing
deep marginalizationwith glass eye armor, that's also called
an open sandwich technique.
That technique was thoroughly debunkedin the late eighties
because the glass monomerswere brittle under functional stresses
they would break down in the years 4 to 6,there are no 20 year
(21:09):
deep margin elevations using glass.
I honor the successful cases,but it's still being taught
in the couple of dental schools aroundwhich it wasn't being taught it.
It'll be good for four or five years,but then you have to redo it
because it breaks down underneathyour composite only in layer restoration.
And that comes from solid science.
(21:31):
The Ph.D. work of Dietschi.
Consider himone of my early mentors, of course,
Ray Bertolotti and Gray Unterbrink.
Didier Dietschi I was veryimpressed with everything
that he was doing as far as minimallyinvasive and adhesive dentistry.
Of course,esthetically just totally beautiful,
(21:51):
and after the course it was actually underthe direction of Ed McLaren at UCLA.
He was teaching a cosmetic dentistrymaster course at UCLA at that time.
But the and Ed McLaren and I were talking,I said,
I think you're the best dentist the world,but who do you think
is the best dentist?
And he without hardly even thinking, saidUrs Belser,
(22:14):
because I hadn't heard his name.
I had read it, but not remembered it.
You wrote part of the introductionto Dietschi’s Book, and Urs
Belser was the mentor of Didier Dietschiand the mentor of Pascal Magne.
And Belser was is a presidentwho mastered all areas of prosthodontics
(22:34):
and all areas of implant dentistryassociated with prosthodontics
and Belser’s a top researcher, teacher,the administrator,
just a great human being from all reports.
I haven't met him personally, but Belserbasically told Dietschi if adhesive
dentistry lives up to his potential,it will eliminate most of the endo.
(22:55):
It will eliminate most of the perio,it will eliminate
prosthodontic destructionof tooth structure.
And so all of the specialty disciplines,including implants,
will be majorly impactedby implementing adhesive dentistry.
Now, if you're a specialist,you might not like to hear that message.
(23:17):
I know when I told Steve Buchananabout the six lessons
21 years ago, he had lunch.
I said, Steve,this is going to prevent a lot of endo.
And he looked at his says, Great, He'svery busy in Santa Barbara.
Still is.
He's still teaching and practicing,I believe in Santa Barbara,
but he changed the world of endodonticsThe world paradigm has changed.
(23:40):
Unfortunately,it's mostly based on extracting teeth
that could be savedwith the periodontal treatments
and good restorative treatmentslike biomimetic dentistry.
But these evolutions Belser was forhe felt like it was progress.
As long as we're conserving to structureand conserving pulp
(24:01):
tissue, Belser understood the differencebetween a vital and a non vital tooth
and all of the investigationssince the early 2000s of reinforce
the idea that a brittlenesscomes from antibiotic treatment
that cannot be remedied.
A tooth that has enteredour treatment has three times
(24:22):
the potential to fracturebecause it's three times as brittle
and it's only a third of the engineeringterm as toughness.
So a toughtooth, tough material flexes
a brittle tooth.
Their brittle material beginsto fracture through crack
initiation, crack propagation,and finally catastrophic failure.
(24:46):
Anyway, the lot to think about.
But here we are change the world.
They'll next time get bonded. They bonded.
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