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
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
and deep cavities of posterior teeth has been adequately
ensured by amalgam or by indirect gold restorations; with the
continuing advancements in material technology and clinical
techniques, alternative and more esthetic types of restorations
have become feasible. Proximal box elevation (PBE) using com-
posite resins has been advocated for relocating subgingival
cavity outlines; treatment success and effects of PBE require
documentation. Data Sources: An electronic search was per-
formed on several literature databases to identify relevant
articles published in indexed journals until April 2015. Method
and Materials: The authors independently screened the rele-
vant papers found (PBE with composite resins). Results: This
paper compiles the current knowledge about PBE (which is
predominantly based on laboratory research, in particular with
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-
tine treatment regimen for posterior teeth,1 in particu-
lar preventive (hampering demineralization and stimu-
1
Professor and Head, Centre for Operative Dentistry, Periodontology, and
Endodontology; and Dean, University of Dental Medicine and Oral Health, Dan-
ube Private University (DPU), Krems, Austria.
2 Undergraduate Student, University of Dental Medicine and Oral Health, Danube
Private University (DPU), Krems, Austria.
Correspondence: Prof Dr Dr h. c. Andrej M. Kielbassa, Centre for Opera-
tive Dentistry, Periodontology, and Endodontology, University of Dental
Medicine and Oral Health, Danube Private University (DPU), Steiner Land-
straße 124, 3500 Krems, Austria. Email: andrej.kielbassa@dp-uni.ac.at
VOLUME 46 • NUMBER 9 • OCTOBER 2015
Andrej M. Fabian Philipp
Kielbassa
that flowable composites allow for a stepwise elevation of
proximal cavity floors, thus simplifying treatment of deep
lesions, and broadening the restorative spectrum. A case
report revealing an advanced caries lesion and demonstrating
the clinical application of the PBE technique together with an
indirect computer-aided design/computer-assisted manufac-
ture (CAD/CAM) all-ceramic restoration is presented, assuring
the practitioner’s familiarity with effective placement tech-
niques. Conclusion: PBE represents a promising two-step
treatment regimen, simultaneously encompassing the benefits
of immediate dentin sealing and facilitating direct or indirect
adhesive restorations of cavities with margins located beneath
the gingival tissues. However, high-quality randomized clinical
trials are required to confirm the laboratory outcomes.
(Quintessence Int 2015;46:751–764; doi: 10.3290/j.qi.a34459)
lating remineralization) and microinvasive approaches
(including the infiltration technique)2 will be empha-
sized to avoid any surgical treatment. However, when it
comes to increased demineralization (along with sur-
face breakdown), timely invasive options for posterior
class II cavities include the use of directly placed com-
posites,3 together with adhesively bonded indirect res-
torations. In many western countries, an increasing
public demand for esthetic solutions can be observed,
and this has been accompanied by a continuous devel-
opment of tooth-colored materials and luting agents
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leading to an increasing use of direct and indirect
esthetic restorations of posterior teeth. This trend
towards non-amalgam restorations has been assisted
by a significant increase in teaching and training in the
use of amalgam alternatives in many dental schools.4
Unfortunately, along with the more frequent use of
adhesive techniques, new clinical problems have
appeared. Proximal caries and cavities of large dimen-
sions extending below the cementoenamel junction
(CEJ) and revealing cavity margins located beneath the
gingival tissues appear to be challenging, since cavity
preparation, impression taking, adhesive bonding pro-
cedures, and proper moisture control might be
impeded. Additionally, with a deep proximal box the
usage of indirect all-ceramic restorations often is ham-
pered (if not considered impossible). It is generally
accepted that contamination with blood5 and/or saliva6
during bonding and cementation procedures weakens
the adhesive bond strength and leads to a possible
failure of the restoration. Therefore, with deep proximal
cavities it is vital to master these clinical steps and to
achieve marginal integrity, which is considered one of
the most important criteria for restoration success.
In cases with large posterior defects, restorations
fabricated from indirect CAD/CAM (computer-aided
design/computer-assisted manufacture) techniques
have proven to be very reliable over long-term periods
of up to 18 years,7 with survival rates very comparable
to direct composite restorations,8 with restoration mar-
gins better than with direct composite fillings,9 and
with acceptable esthetic outcomes even with under-
graduates.10 Furthermore, the use of chairside CAD/
CAM systems enables the clinician to process all-ce-
ramic restorations in a single visit. This is considered
advantageous, since, from a biologic point of view, the
immediate dentin sealing (IDS) will avoid any bacterial
contamination during the provisional phase. Teeth
restored with bonded ceramic inlays show biologic
compatibility, adequate compressive strength, similar
thermal conductivity to dental tissues, marginal integ-
rity, and color stability.9,11
To make treatments in those cases less fault-prone,
the application of a composite resin attached to and
752
elevating the proximal box floor as described by Dietschi
and Spreafico12 may be an option. The recently reevalu-
ated process flow in such cases involves the application
of a composite resin using a diligent layering technique
to relocate the cavity margins from deep proximal areas
with the aim to facilitate rubber dam application (fol-
lowed by a direct or indirect restoration),13 thus ensuring
that oral fluid control is possible and reducing possible
stress effects from polymerization shrinkage.14,15 In the
current literature, this technique has been named prox-
imal box elevation (PBE),13,16-18 proximal margin eleva-
tion,19 margin relocation,20-22 or open-sandwich tech-
nique.14,23-25 The objective of this paper is to review the
scientific backgrounds of the PBE technique, to discuss
possible benefits and potential drawbacks, and to pres-
ent a clinical case considered representative.
METHOD AND MATERIALS
Search strategy
This review’s methodology was adopted from PRISMA
(Preferred Reporting Items for Systematic Reviews and
Meta-Analyses).26 An electronic search with no restric-
tions regarding dates was performed on EBSCOhost,
EMBASE, PubMed/MEDLINE, and Scopus (up to April
2015). The search was completed by use of Google
Scholar, thereby cross-checking the results for relevant
publications in indexed journals; Google Scholar pro-
vides some advantages over other retrieval systems like
easy initial retrieval of possibly worthwhile articles and
the ability to find citations to older items.27 The main
search terms were “margin relocation”, “proximal box
elevation”, “proximal margin elevation [technique]”,
and “open-sandwich [technique or restoration]” (with
composite resin restorations below the CEJ of perma-
nent teeth). In addition, reference lists of potential
publications to be included in the review were
explored for other relevant papers.
Selection criteria
This review sought for in vitro studies and randomized
controlled trials (RCTs) on PBE and related terms in per-
manent teeth (see above). Publications not focusing on
VOLUME 46 • NUMBER 9 • OCTOBER 2015

restorations beneath the gingival tissues or the CEJ
were excluded.
Screening process
The two review authors performed the search and
selection process (finished on 11 April 2015). After the
initial screening of titles and abstracts, full papers were
analyzed, and differences between the reviewers were
resolved through discussion.
REVIEW RESULTS
Literature search
The initial search yielded 30 available titles in EBSCO-
host, 32 in EMBASE, 87 in PubMed/MEDLINE, and 41 in
Scopus, with four papers (double or multiple retrievals)
found in all databases mentioned. In total, 170 studies
not fitting the eligibility criteria of this review were
excluded after careful reading. Thus, 19 studies pub-
lished between 2003 and 2015 were included in this
review. In total, the search resulted in 15 in vitro stud-
ies, three in vivo studies and one in vitro/in vivo com-
parison relevant to the topic. A summary of all in vitro
studies included in the current paper is provided in
Table 1. Due to the low number of clinical trials and the
heterogeneity of the in vitro studies included, further
statistical analyses were not considered appropriate.
Study characteristics
The characteristics of the included studies are shown in
Table 1. With the 15 selected in vitro studies, a total of
672 human teeth were treated and analyzed. Most
papers referred to the marginal adaption and/or the
microleakage of the relocated cervical mar-
gins.13,16,18-20,22,23,25,28-33 The marginal adaption was
assessed by examining gaps between tooth tissue and
restoration using scanning electron microscopy (SEM)
using epoxy resin replicas. Microleakage was measured
by using dye penetration methods. Moreover, fracture
resistance and effects of delayed light curing were
examined.16,24,25,28,31,33 Only four papers reported clinical
data,14,15,34,35 with follow-ups from 2 months36 up to 9
years, whereas two of them had the same basis.14,15
VOLUME 46 • NUMBER 9 • OCTOBER 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L
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Marginal adaption: in vitro studies
In total, 13 of the 15 studies13,16,18-20,24,25,28-33 focused on
indirect or direct restorations. The investigated speci-
mens underwent a thermomechanical load-
ing,13,16,18-20,24,30 or a thermocycling procedure23-25,28-33 to
simulate in vivo conditions, and to draw any conclu-
sions about the potential clinical longevity of the ma-
terials used. This may elucidate an initial tendency on
the clinical adequacy of the PBE technique. No signifi-
cant differences between elevated and non-elevated
margins of proximal boxes could be ascertained, either
by means of microleakage testing,23,25,32 or by using
SEM techniques to evaluate marginal integrity.13,16,18-20,22
However, the available literature contains substantial
controversy about preferred base materials; while some
authors have recommended (resin-modified) glass ion-
omers (primarily because high-caries-risk patients
might benefit from the material’s fluoride release, but
with high dissolution rates),14,37,38 others have favored
flowable composite resins (with a lower modulus of
elasticity) since microleakage was decreased compared
to other materials.28-30,32
Effects on fracture resistance: in vitro studies
Root canal treatment had no significant influence on
the marginal adaption or the fracture resistance of the
specimens.16 Fracture resistance was increased by
applying a flowable composite liner in Class 2 amalgam
restorations.24
Other observations: in vitro studies
A delayed light-curing procedure could decrease
microleakage according to some authors.25,28,31 With a
similar effect, soft-start polymerization was tested,
showing no leakage in enamel margins and producing
similar values to those of conventional techniques for
dentin margins.33
Complications: clinical trials
Mechanical complications such as fractures of restor-
ations (compomer-based PBE vs direct composite resin
restoration) could not be observed after 3 years of
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-
ically, neither plaque nor signs of caries (see normal enamel
translucency and texture) were visible. Gentle probing using a
WHO probe did not reveal any increased attachment loss.
a b
after the 9-year evaluation.14 However, biologic compli-
cations such as secondary caries were observed in eight
cases.14 Notwithstanding, no group indicated a higher
number of mechanical complications due to a specific
technique, and no clinical advantage was attributed to
any of the techniques used.14 This was corroborated by
a 6-year clinical study (comparing two different adhe-
sive/composite resin systems); here, neither recurrent
caries nor discolorations were detected.34 None of the
included clinical papers focused on gingival or peri-
odontal effects.
CASE REPORT
A 25-year-old Caucasian man with a complete dentition
presented to the outpatient clinic (Danube Private Uni-
versity, Krems, Austria) for a routine dental check-up.
His medical history was non-contributory to routine
756
Fig 1b Immediately after probing, increased bleeding from the
proximal site of the permanent left second maxillary molar could
be observed, suggesting severe papillary inflammation and indi-
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
compared to the conventional radiograph (compare Fig 2a).
dental care. An extraoral examination revealed no
swellings, asymmetries, or sensitivities in the head and
neck areas. The mucosae were healthy pink, non-in-
flamed, and showed no macroscopic signs of lesions or
ulceration. Periodontal screening revealed non-in-
creased probing pocket depths; however, bleeding of
the gingiva after gentle probing of the mesial site of
the left second maxillary molar was observed (Fig 1).
The clinical examination of the asymptomatic and vital
tooth revealed a small surface defect located at the
central groove, with signs of active caries and occlusal
surface breakdown.
A bitewing radiograph (Heliodent Plus, Sirona Den-
tal Systems; 68 kV/0.08 s) revealed a deep manifest
lesion, obviously non-cavitated but progressing into
dentin and undoubtedly requiring restorative treat-
ment (Fig 2a). Additionally, cone beam computed
tomography (CBCT, Galileos; Sirona Dental Systems)
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Fig 3a Preoperative CBCT
scan (occlusal view), corrobor-
ating caries extension in pulpal
direction and breakdown of
proximal enamel surface (com-
pare Fig 2).
Fig 3b Preoperative occlusal
view (with localized surface
defect/microcavity of the cen-
tral groove) after disinfection of
the operating field and rubber
dam placement (note that at
this clinical level detection of
the advanced stage of proximal
caries was not possible).
Fig 3c Intraoperative view
showing that isolation with
rubber dam did not prevent
from excessive bleeding, due
to subgingival extension of
proximal box floor.
Fig 3d After meticulous iso-
lation of completed cavity
preparation, the proximal box
was isolated using a Tofflemire
matrix band and a wooden
wedge to ensure tight proxim-
ation. Dentin bonding using a
three-step adhesive followed
after acid etching.

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

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Fig 3e Application of both
flowable and viscous compos-
ite resin. Note that adequate
isolation was achieved, and no
contamination occurred.
Fig 3f After final polymeriza-
tion was accomplished using a
light source operating at 1200
mW/cm2, finishing of the prox-
imal margins followed with
polishing strips.
Fig 3g Virtual construction
after optical scanning/digital
impression of ceramic inlay
using CAD/CAM chairside
technology.
Fig 3h Final preparation
design, with relocated prox-
imal margin. Rubber dam was
re-placed below the new cavity
outline, thus enabling further
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-
generated adhesive ceramic
inlay restoration.
Fig 3j For safe bonding, PBE
composite resin was primed.
Ceramic inlay was etched and
silanized, and adhesively luted.
Fig 3k Final clinical view of Fig 3l Clinical appearance 3
finished restoration (perma- months after treatment. Patient
nent left second maxillary was satisfied, and did not
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
curing for 40 seconds (Silverlight, GC) the matrix was
removed and the preparation was finished with focus
on optimum all-dimension thickness of the ceramic,
sufficient wall thickness of the tooth, carefully round-
ed-off inner transitions, and obtuse angles of prepar-
ation margins to allow for accurate digital scanning of
the prepared cavity. The preparation was finished using
bucket-shaped diamond burs with rounded shoulders
(8847KR, 8845KR; Komet) to remove the oxygen layer
and to provide ideal taper; simultaneously, enamel
margins were carefully re-finished, thereby removing
excess adhesive resin.
Finishing of the elevated proximal margins was
accomplished using flexible disks (Sof-Lex, 3M Espe) of
decreasing grit and polishing strips (Epitex, GC; Fig 3f).
Finally, rubber dam was removed and a digital impres-
sion using the Cerec Omnicam (Sirona Dental Systems)
was made. Optical scans of the antagonist teeth fol-
lowed for adjustment of the static occlusion. After veri-
fying the final restoration design (Fig 3g), the inlay was
milled from a ceramic block (IPS Empress CAD, A2 I8;
Ivoclar Vivadent) using a Cerec MC XL Milling Unit
(Sirona Dental Systems). After re-application of rubber
dam (Fig 3h), try-in of the polished restoration fol-
lowed, presenting adequate fit (Fig 3i). For safe bond-
ing, the PBE composite resin was primed (GC), and the
ceramic inlay was etched and silanized (IPS Ceramic
Etching Gel and Monobond Plus; Ivoclar Vivadent);
finally, the indirect ceramic restoration was adhesively

758 VOLUME 46 • NUMBER 9 • OCTOBER 2015


luted (Total Etch, Syntac Primer/Adhesive, Heliobond,
and Variolink II A1; Ivoclar Vivadent; Fig 3j).
After rubber dam removal, any retained excess resin
cement remnants were removed, and appropriate
tightness of proximal tooth contact was confirmed with
a sticking Tofflemire matrix (50 μm; Hawe). Static and
dynamic occlusion were evaluated using articulating
paper (Arti-Check, 40 μm; Bausch). Dental floss was
passed interproximally to ensure patency and ability for
oral hygiene by snapping in and out with firm resis-
tance. Finally, the restoration was polished using
ceramic polishers (187–189; Komet), followed by a dia-
mond polishing paste (DirectDia, Shofu Dental) and a
brush (Jiffy, Ultradent) until a smooth transition from
the tooth surface onto the restoration was assured
(Fig 3k). To complete the treatment a fluoride gel (Sen-
sodyne Proschmelz Fluorid Gelée, GlaxoSmithKline)
was applied topically, and the patient received motiva-
tion and oral hygiene instructions. The 3-month fol-
low-up is shown in Fig 3l. Figure 4 presents the buccal
view, highlighting the non-inflamed papilla.
DISCUSSION
Basically, PBE is not a new treatment regimen, since the
principle behind this restorative procedure refers to the
open-sandwich technique. Essentially, PBE and
open-sandwich technique describe the same proced-
ures. With the conventional open-sandwich restoration,
a substantial part of the restoration was replaced with
a glass-ionomer cement (GIC), the latter covering sub-
stantial parts of the exposed dentinal surface of the
cavity, and extending to the periphery of the proximal
box to form a new cervical seal (being exposed to the
oral environment).14 However, with the open-sandwich
technique using GIC, high clinical failure rates have
been reported,39,40 and, thus, modifications using res-
in-modified GICs, polyacid-modified composite resins,
or low viscosity (flowable) composite resins have been
introduced later on with acceptable outcomes in the
long term.14,15,41
The main clinical aims behind both the PBE and the
open-sandwich technique, are to facilitate adhesive
VOLUME 46 • NUMBER 9 • OCTOBER 2015
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restorations in areas difficult to access, to reduce frac-
ture susceptibility, and to increase the marginal adap-
tion of Class 2 restorations, by applying a (long-lasting)
base beneath the restoration which is open to the oral
environment. It has been suggested that such restor-
ations might reduce secondary caries incidence due to
good marginal sealing.23 However, some of the studies
included in the current review did not support the use
of certain materials classes (such as [resin-modified]
glass ionomers).13,16,18,22 Clinically relevant differences
could be detected when using self-adhesive resin
cements (Maxcem Elite, Kerr), and these obviously were
not suitable for PBE.13 However, with a meticulous lay-
ering technique and bonded composite resin, it was
concluded that PBE could be an alternative to conven-
tional adhesive luting to dentin,13 with satisfactory
performance in terms of wear of occlusal and proximal
contacts.42
Marginal gaps along the interface between restor-
ation and cavity floor and walls are considered stagna-
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-
ation. With timely bonding agents, no clinically consid-
erable complications like discolorations or secondary
caries were detected in a previously published prospec-
tive clinical trial after 6 years,34 even if the simultane-
ously performed in vitro study (using water storage and
thermomechanical loading) revealed a significant
decrease of gap-free dentin margins with Class 2 prox-
imal boxes.34 To improve marginal adaptation of PBE
restorations (with decreased microleakage and fewer
voids), the use of flowable composite resins has been
advocated.24,32 Moreover, when using (dual) cured com-
posite resins as a base on the proximal box floor,
delayed light curing25,31 or soft-start polymerization33
seems to be advantageous, possibly due to an improved
arrangement of the composite molecules, and thus
leading to (polymerization) stress release.33 This sheds
some light on the viscous composite resins’ penetration
ability which is increased with additional time.43
With proximal cavities of large and subgingival
dimensions, handling difficulties are very common, and
759
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Kielbassa/Philipp
Fig 4a Clinical appearance 3 months after diagnosis and invasive
treatment of caries lesion. Probing did not reveal increased prob-
ing depths, and no clinical signs of papillary inflammation recur-
rence could be observed (compare to Fig 1).
these are due to inferior cavity inspection and access,
deficient management of undercuts, hampered pro-
cessing of proximal margins, and limited moisture
control. Not astonishingly, these areas could cause
problems with regard to imperfect restorations pro-
moting plaque accumulation and retention, thus lead-
ing to chronic localized gingivitis, periodontitis, and
attachment loss. Consequently, crown and fixed/
removable partial denture work as well as amalgam
restorations have been associated with inflammation,
alveolar crest resorption, and periodontal breakdown;
however, this obviously was not associated with com-
posite resins and glass ionomers.44 Accordingly, the
amount of plaque and the degree of gingivitis adjacent
to (polished) composite fillings were not significantly
higher than those for the GIC and enamel surfaces.45
With resin-modified GICs, compomers, and composite
resins, this was corroborated; here, the various mater-
ials did not result in measurable differences concerning
clinical or subclinical signs of gingivitis.46
These findings indeed seem to challenge merits and
clinical relevance of laboratory studies on microleakage
and marginal integrity (the latter representing the
majority of non-standardized investigations compiled
in the current review; see Table 1). However, when scru-
tinizing the value of in vitro studies, it should be
emphasized that the main advantage of such non-clin-
ical testing would seem the general differences among
different treatment methods and/or various tech-
760
Fig 4b Immediately after probing, no bleeding could be
observed from the proximal gingiva, suggesting that periodontal
tissues were healthy and tolerated violation of biologic width.
niques, but extrapolation to the in vivo situation
remains difficult. For example, it is well known that
resin-modified GICs or polyacid-modified composite
resins (absorbing water/showing hygroscopic expan-
sion) have inferior mechanical properties when com-
pared to composite resins, a comparably rough surface
finish, and high solubility rates;41 however, these mater-
ials have shown acceptable clinical results so far.34,35
Similar considerations may be taken into account
for flowable composite resins. These materials have
been assumed to improve marginal adaptation and
seal, and to act as a stress-absorbing layer beneath a
filled hybrid composite resin restoration. However,
these flowables also have inferior mechanical proper-
ties. From Table 1, it seems clear that the effects are
material dependent, with either positive24,28,32 or nega-
tive29,30 outcomes when placed underneath conven-
tional hybrid composites.
These thoughts directly lead to the question of
whether the biologic width will be affected by a PBE
procedure.17 It is generally accepted, that violations of
the biologic width will result in gingival inflammation,
loss of periodontal attachment, and inflammatory bone
resorption. Notwithstanding, minor violations of lim-
ited extent and with small but perfectly adjusted com-
posite surface areas have been assumed to be non-det-
rimental, in particular in cases of maintained oral
hygiene measures (see Figs 1 and 4).17 From a peri-
odontal point of view, it seems indeed conceivable that
VOLUME 46 • NUMBER 9 • OCTOBER 2015

in these cases the organism will be able to restore the
biologic width (without the need of surgical interven-
tion or orthodontic extrusion), or will adapt to the new
one.47 This has been corroborated by a recent study
revealing that adhesive fragment reattachment using
composite resins did not affect periodontal health.48
With regard to the etiology of gingivitis, it is well-
known that the latter is caused by a chronic biofilm-as-
sociated (non-specific) inflammation caused by a poly-
microbial infection; there is a clear correlation between
microbial deposits and papillary inflammation. How-
ever, this not only is a matter of (daily) oral hygiene, but
refers also to site-specific niches of iatrogenic origin (ie,
overhangs and excess of restorative materials); addi-
tionally (but not always taken into account), caries
lesions are obstacles to effective oral hygiene, in partic-
ular with respect to the clinically invisible approximal
lesions in teenagers or young adults (see Fig 1).49 While
the occurrence of plaque does not have a comparable
predictive power, bleeding on probing helps with the
treatment decision, indicating that there is lesion prog-
ress49 or cavitation50 (with the latter unambiguously
being a plaque retention site; see Fig 2), and suggest-
ing to initiate operative treatment.
With regard to diagnostics, initial and even moder-
ate stages of approximal caries often are not detectable
at the clinical level. Thus, bitewing radiographs are
considered an essential prerequisite facilitating treat-
ment decision; it is commonly accepted that once the
caries lesion extends radiographically into (outer) den-
tin, a loss of surface integrity is most likely to occur.50
Concomitantly, this surface breakdown will provide
retention sites for dental biofilm accumulation, empha-
sizing the need for an inescapable therapeutic inter-
vention.51 Based on these requirements, the extent of
the caries lesion on the left second maxillary molar into
dentin was obvious from the initial bitewing radio-
graph; however, this radiograph did not demonstrate a
communication between the tooth’s lesion and the oral
cavity, since no surface damage was apparent (see
Fig 2a), thus corroborating previous reports of low cav-
itation detection rates.50 Nonetheless, corresponding to
the papillary inflammation and the entertained suspi-
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cion of proximal caries (see Fig 1),49 severe cavity forma-
tion was obvious from the CBCT scans (compare Figs 2b
and 3a), thus highlighting the increased sensitivity of
this imaging technology,52 and elucidating the ability to
additionally provide valuable information that helps
with diagnosis and treatment decision.
The clinical application of the PBE technique
described in the present case report was performed
using a three-step etch-and-rinse adhesive system
(Syntac, Ivoclar Vivadent) mediating a physically stable
bond between dentin and composite resin (G-ænial
Universal Flo and G-ænial, GC, as well as Heliobond and
Variolink, Ivoclar Vivadent). This was followed with an
indirect CAD/CAM leucite-based glass-ceramic restor-
ation (IPS Empress CAD, Ivoclar Vivadent). The decision
to perform a PBE was based on the deep location of the
carious defect and the concomitant difficulties achiev-
ing an adequate isolation for digital impression and
adhesive cementation of the secondary restoration. It is
known that using an appropriate pre-conditioning
technique will result in reliable bond strengths
between composite resin (bases or build-ups) and
ceramics.53 From a clinical perspective, this regimen
was justified from several papers confirming the posi-
tive prognosis of this kind of treatment.9,13,16,20,34
Indirect treatment of posterior proximal cavities
revealing extensions below the CEJ is clinically ambi-
tious, due to difficulties in achieving an adequate mois-
ture control.13 When encountering such clinical situa-
tions it is a considerable option to relocate the proximal
box floor, using a composite resin in order to facilitate
rubber dam application and adhesive luting proced-
ures (see Fig 3h), in particular if several adjacent cavities
have to be treated.13 PBE additionally ensures further
requirements like eliminating undercuts and allows
proximally undermining caries to be restored minimally
invasively to limit the size of the prepared cavities for
indirect restorations, thus preventing extensive sub-
stance loss,18 improving cuspal reinforcement,11 and
compensating for limited polymerization with deep
defects. It should be emphasized that composite resin
restorations do not serve only for their inherent
esthetic qualities; instead, conservative cavity prepar-
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Kielbassa/Philipp
ations with traditional configurations (as used for amal-
gam in the past) are not considered mandatory any-
more; thus, sound tooth substance can be preserved,
and this is an undisputable advantage of direct com-
posite fillings.
Due to the nature of a deep proximal box, air-drying
procedures often are not efficient, and pooling of water
or adhesive in the cavity corners frequently occurs.
Such ineffective drying and pooling effects have been
shown to impair adequate removal of solvent and
water, subsequently decreasing the strengths of adhe-
sive bonding which is the basis for a successful restor-
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
application techniques (eg, the “snow plough tech-
nique”).17
A further advantage of the PBE technique is the
immediate dentin sealing (IDS) which is performed
concomitantly with the PBE procedure. In case a signif-
icant area of dentin is exposed during the preparation
for an indirect restoration, evidence supports the appli-
cation of an adhesive resin coating to the freshly cut
and conditioned dentin, thus creating a collagen fibril
reinforced complex interphase. This procedure includes
advantages like increased retention, reduced marginal
leakage, improved bond strengths, and decreased post-
operative sensitivity.55 Thus, the sealed dentin is pro-
tected from bacterial invasion during the provisional
phase, and the luting procedure of any definite porce-
lain restoration requires less or no anesthetics at all.
An optimal digital impression is fundamental to any
CAD/CAM restoration, since image quality, accuracy,
and precision of the acquired image is equivalent to
the precision of the final outcome. However, digital
impressions of deep cavities in the molar region can be
challenging due to the limited space available and the
restrictions of the used digital system’s scanning
depths. By elevating the proximal box, a digital scanner
can provide more accurate results if compared to deep
cavities. Furthermore, the scanning procedure is much
easier to handle and will be accelerated. With an ade-
quate isolation the overall result will be satisfying, since
762
no saliva or blood contamination will impede the out-
come of the digital impression.
Since most adhesive cements are photopolymer-
ized, sufficient light-curing through the secondary
(indirect) restoration is crucial for clinical success. How-
ever, when facing a deep proximal box, sufficient
light-curing of luting composites or bonding agents via
the secondary restoration might be less efficient. Con-
sequently, sufficient polymerization is impeded when
encountering a deep proximal box. With these situa-
tions, PBE might be an alternative to solve this complex
of problems.
CONCLUSIONS
From a clinical point of view, the PBE technique (in
combination with an indirect CAD/CAM restoration)
undoubtedly has several advantages:
• IDS will increase the physical performance of the
adhesively luted base
• microbial invasion and postoperative pain will be
avoided
• oral fluid control will be facilitated
• quality of digital (or analog) impressions will be
improved
• design of proximal contact will be enabled
• overall time spent with adhesively bonded compos-
ite resin or indirect restorations will be shortened.
Given an adequate isolation technique, the use of
appropriate materials, and careful handling of the lat-
ter, PBE is considered a promising restorative comple-
tion to facilitate treatment of advanced caries lesions
with dentin/cementum margins located beneath the
gingival tissues.
Currently, valid knowledge of PBE is primarily based
on laboratory studies; notwithstanding, PBE using flow-
able composite resins seems to be a viable and reason-
able treatment option, representing a valuable addition
to the dental clinician’s armamentarium. With regard to
possible implications for research, the moderate num-
ber of clinical trials highlights the field of major interest.
Therefore, more high-quality research (reasonably cov-
VOLUME 46 • NUMBER 9 • OCTOBER 2015

ering both cariologic and periodontal aspects, and
focusing on the clinical durability of PBE as a two-step
restoration technique) is warranted.
REFERENCES
1. Kielbassa AM, Lynch CD, Wilson NH. The Minamata convention: the begin-
ning of the (amalgam-free) future? Quintessence Int 2014;45:547–548.
2. Kielbassa AM, Muller J, Gernhardt CR. Closing the gap between oral hygiene
and minimally invasive dentistry: a review on the resin infiltration technique
of incipient (proximal) enamel lesions. Quintessence Int 2009;40:663–681.
3. Lynch CD, Opdam NJ, Hickel R, et al. Guidance on posterior resin composites:
Academy of Operative Dentistry - European Section. J Dent 2014;42:377–383.
4. SCENIHR. (Scientific Committee on Emerging and Newly-Identified Health
Risks). Scientific opinion on the safety of dental amalgam and alternative
dental restoration materials for patients and users (update; 26 August 2014).
Available at: http://ec.europa.eu/health/scientific_committees/emerging/
docs/scenihr_o_046.pdf. Accessed 11 April 2015.
5. Juneja R, Duhan J, Tewari S, Sangwan P, Bhatnagar N. Effect of blood contam-
ination and decontamination protocols on acetone-based and ethanol-based
total etch adhesive systems. J Esthet Restor Dent 2014;26:403–416.
6. Santschi K, Peutzfeldt A, Lussi A, Flury S. Effect of salivary contamination and
decontamination on bond strength of two one-step self-etching adhesives to
dentin of primary and permanent teeth. J Adhes Dent 2015;17:51–57.
7. Reiss B. Clinical results of Cerec inlays in a dental practice over a period of 18
years. Int J Comput Dent 2006;9:11–22.
8. Thordrup M, Isidor F, Horsted-Bindslev P. A prospective clinical study of indi-
rect and direct composite and ceramic inlays: ten-year results. Quintessence
Int 2006;37:139–144.
9. Zaruba M, Kasper R, Kazama R, et al. Marginal adaptation of ceramic and
composite inlays in minimally invasive MOD cavities. Clin Oral Investig
2014;18:579–587.
10. Wrbas KT, Hein N, Schirrmeister JF, Altenburger MJ, Hellwig E. Two-year clin-
ical evaluation of Cerec 3D ceramic inlays inserted by undergraduate dental
students. Quintessence Int 2007;38:575–581.
11. Zamboni SC, Nogueira L, Bottino MA, Sobrinho LC, Valandro LF. The effect of
mechanical loading on the cusp defection of premolars restored with direct
and indirect techniques. J Contemp Dent Pract 2014;15:75–81.
12. Dietschi D, Spreafico R. Current clinical concepts for adhesive cementation of
tooth-colored posterior restorations. Pract Periodontics Aesthet Dent
1998;10:47–54.
13. Frankenberger R, Hehn J, Hajto J, et al. Effect of proximal box elevation with
resin composite on marginal quality of ceramic inlays in vitro. Clin Oral Inves-
tig 2013;17:177–183.
14. Lindberg A, van Dijken JW, Lindberg M. Nine-year evaluation of a polyac-
id-modified resin composite/resin composite open sandwich technique in
Class II cavities. J Dent 2007;35:124–129.
15. Lindberg A, van Dijken JW, Lindberg M. 3-year evaluation of a new open
sandwich technique in Class II cavities. Am J Dent 2003;16:33–36.
16. Ilgenstein I, Zitzmann NU, Buhler J, et al. Influence of proximal box elevation
on the marginal quality and fracture behavior of root-filled molars restored
with CAD/CAM ceramic or composite onlays. Clin Oral Investig 2015;219:1021–
1028.
17. Frese C, Wolff D, Staehle HJ. Proximal box elevation with resin composite and
the dogma of biological width: clinical R2-technique and critical review. Oper
Dent 2014;39:22–31.
18. Roggendorf MJ, Kramer N, Dippold C, et al. Effect of proximal box elevation
with resin composite on marginal quality of resin composite inlays in vitro. J
Dent 2012;40:1068–1073.
VOLUME 46 • NUMBER 9 • OCTOBER 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L
Kielbassa/Philipp
19. Zaruba M, Gohring TN, Wegehaupt FJ, Attin T. Influence of a proximal margin
elevation technique on marginal adaptation of ceramic inlays. Acta Odontol
Scand 2013;71:317–324.
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
microtensile bond strength. Med Oral Patol Oral Cir Bucal 2012;17(Suppl 2).
22. Lefever D, Gregor L, Bortolotto T, Krejci I. Supragingival relocation of subgin-
givally located margins for adhesive inlays/onlays with different materials. J
Adhes Dent 2012;14:561–567.
23. Shafiei F, Akbarian S. Microleakage of nanofilled resin-modified glass-iono-
mer/silorane- or methacrylate-based composite sandwich Class II restoration:
effect of simultaneous bonding. Oper Dent 2014;39:E22–E30.
24. Guray Efes B, Yaman BC, Gumustas B, Tiryaki M. The effects of glass ionomer
and flowable composite liners on the fracture resistance of open-sandwich
class II restorations. Dent Mater J 2013;32:877–882.
25. Atlas AM, Raman P, Dworak M, Mante F, Blatz MB. Effect of delayed light poly-
merization of a dual-cured composite base on microleakage of Class 2 poste-
rior composite open-sandwich restorations. Quintessence Int
2009;40:471–477.
26. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med
2009;6:e1000097.
27. Shultz M. Comparing test searches in PubMed and Google Scholar. J Med Libr
Assoc 2007;95:442–445.
28. Bhanwal U, Nadig RR, Jagdish K, Pai V, Yashwanth Y. Effect of different base
materials and techniques on microleakage in class II composite open sand-
wich restorations: an in vitro study. World J Dent 2014;5:87–91.
29. Moazzami SM, Sarabi N, Hajizadeh H, et al. Efficacy of four lining materials in
sandwich technique to reduce microleakage in class II composite resin restor-
ations. Oper Dent 2014;39:256–263.
30. Sawani S, Arora V, Jaiswal S, Nikhil V. Comparative evaluation of microleakage
in Class II restorations using open vs. closed centripetal build-up techniques
with different lining materials. J Conserv Dent 2014;17:344–348.
31. Kamath U, Sheth H, Vigneshwar V. Role of delayed light polymerization of a
dual-cured composite base on marginal adaptation of class II posterior com-
posite open-sandwich restoration. Indian J Dent Res 2012;23:296.
32. Fabianelli A, Sgarra A, Goracci C, Cantoro A, Pollington S, Ferrari M. Microleak-
age in class II restorations: open vs closed centripetal build-up technique.
Oper Dent 2010;35:308–313.
33. Rodrigues Junior SA, Pin LF, Machado G, Della Bona A, Demarco FF. Influence
of different restorative techniques on marginal seal of class II composite res-
torations. J Appl Oral Sci 2010;18:37–43.
34. Garcia-Godoy F, Kramer N, Feilzer AJ, Frankenberger R. Long-term degrada-
tion of enamel and dentin bonds: 6-year results in vitro vs. in vivo. Dent Mater
2010;26:1113–1118.
35. Andersson-Wenckert IE, van Dijken JW, Horstedt P. Modified Class II open
sandwich restorations: evaluation of interfacial adaptation and influence of
different restorative techniques. Eur J Oral Sci 2002;110:270–275.
36. Figueiredo Reis A, Giannini M, Ambrosano GM, Chan DC. The effects of filling
techniques and a low-viscosity composite liner on bond strength to class II
cavities. J Dent 2003;31:59–66.
37. Loguercio AD, Alessandra R, Mazzocco KC, et al. Microleakage in class II com-
posite resin restorations: total bonding and open sandwich technique. J
Adhes Dent 2002;4:137–144.
38. Kirsten GA, Rached RN, Mazur RF, Vieira S, Souza EM. Effect of open-sandwich
vs. adhesive restorative techniques on enamel and dentine demineralization:
an in situ study. J Dent 2013;41:872–880.
39. van Dijken JW. A 6-year evaluation of a direct composite resin inlay/onlay
system and glass ionomer cement-composite resin sandwich restorations.
Acta Odontol Scand 1994;52:368–376.
763
Q U I N T E S S E N C E I N T E R N AT I O N A L
Kielbassa/Philipp
40. Welbury RR, Murray JJ. A clinical trial of the glass-ionomer cement-composite
resin “sandwich” technique in Class II cavities in permanent premolar and
molar teeth. Quintessence Int 1990;21:507–512.
41. Andersson-Wenckert IE, van Dijken JW, Kieri C. Durability of extensive Class II
open-sandwich restorations with a resin-modified glass ionomer cement
after 6 years. Am J Dent 2004;17:43–50.
42. Sachdeo A, Gray GB, Sulieman MA, Jagger DC. Comparison of wear and clin-
ical performance between amalgam, composite and open sandwich restor-
ations: 2-year results. Eur J Prosthodont Restor Dent 2004;12:15–20.
43. Paris S, Meyer-Lueckel H, Colfen H, Kielbassa AM. Penetration coefficients of
commercially available and experimental composites intended to infiltrate
enamel carious lesions. Dent Mater 2007;23:742–748.
44. Ababnaeh KT, Al-Omari M, Alawneh TN. The effect of dental restoration type
and material on periodontal health. Oral Health Prev Dent 2011;9:395–403.
45. van Dijken JW, Sjostrom S. The effect of glass ionomer cement and composite
resin fillings on marginal gingiva. J Clin Periodontol 1991;18:200–203.
46. van Dijken JW, Sjostrom S. Development of gingivitis around aged restor-
ations of resin-modified glass ionomer cement, polyacid-modified resin
composite (compomer) and resin composite. Clin Oral Investig 1998;2:180–
183.
47. Ramfjord SP. Periodontal considerations of operative dentistry. Oper Dent
1988;13:144–159.
764
48. Eichelsbacher F, Denner W, Klaiber B, Schlagenhauf U. Periodontal status of
teeth with crown-root fractures: results two years after adhesive fragment
reattachment. J Clin Periodontol 2009;36:905–911.
49. Ekstrand KR, Bruun G, Bruun M. Plaque and gingival status as indicators for
caries progression on approximal surfaces. Caries Res 1998;32:41–45.
50. Kielbassa AM, Paris S, Lussi A, Meyer-Lueckel H. Evaluation of cavitations in
proximal caries lesions at various magnification levels in vitro. J Dent
2006;34:817–822.
51. Kielbassa AM, Meyer-Lueckel H, Lussi A. Proximal caries: diagnosis and treat-
ment decision. In: Heidemann D (ed). Deutscher Zahnärzte Kalender 2003.
Köln: Deutscher Zahnärzteverlag, 2003;62:37–58.
52. Tyndall DA, Rathore S. Cone-beam CT diagnostic applications: caries, peri-
odontal bone assessment, and endodontic applications. Dent Clin North Am
2008;52:825–841.
53. Bitter K, Paris S, Hartwig C, Neumann K, Kielbassa AM. Shear bond strengths
of different substrates bonded to lithium disilicate ceramics. Dent Mater J
2006;25:493–502.
54. De Munck J, Arita A, Shirai K, Van Landuyt KL, Coutinho E, Poitevin A, Peumans
M, Lambrechts P, Van Meerbeek B. Microrotary fatigue resistance of a HEMA-
free all-in-one adhesive bonded to dentin. J Adhes Dent 2007;9:373–379.
55. Magne P. Immediate dentin sealing (IDS) for tooth preparations. J Adhes Dent
2014;16:594.
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