Polymer-based restorative outcomes following deep margin elevation: a systematic review and meta-analysis

Deep margin elevation (DME), also known as cervical margin relocation or proximal box elevation, has been proposed as a minimally invasive approach for managing subgingival margins and facilitating adhesive placement of indirect restorations. By relocating deep proximal margins coronally, DME improves isolation and enhances bonding procedures. The technique relies primarily on resin-based polymeric materials, including conventional, flowable, bulk-fill, and injectable composites, as well as resin-modified glass ionomer cements. These materials exhibit distinct polymerization behavior, shrinkage stress, and interfacial properties, which may influence marginal adaptation and long-term clinical performance. However, the clinical relevance of these material-dependent differences remains unclear.

This systematic review and meta-analysis aimed to evaluate the clinical performance of indirect restorations placed after DME, with particular emphasis on the role of polymer-based restorative materials.

A comprehensive electronic search of PubMed/MEDLINE, Scopus, Web of Science, Scielo, and Embase was conducted from inception to March 2026. Randomized clinical trials and prospective or retrospective clinical studies assessing indirect restorations placed following DME in permanent teeth were included. Primary outcomes were restoration survival and success. Secondary outcomes included marginal adaptation, secondary caries, postoperative sensitivity, periodontal parameters, and technical complications. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) and Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I) tools, and the certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. When applicable, meta-analysis was performed using a random-effects model, and heterogeneity was assessed using Cochran's Q and I ² statistics.

Ten clinical studies involving approximately 623 teeth met the inclusion criteria. Restoration survival ranged from 93% to 100% over follow-up periods of 6 months to 12 years. Resin-based composite materials, including flowable, bulk-fill, and injectable systems, demonstrated comparable clinical performance in terms of survival, marginal integrity, and periodontal stability. No statistically significant differences were observed for secondary caries or postoperative sensitivity (p > 0.05). Periodontal parameters remained generally stable. Although a statistically significant increase in bleeding on probing at relocated margins was observed in the meta-analysis (p = 0.02), the absolute increase was clinically modest (mean BoP ranging from 12% to 24% at DME sites vs. 8% to 16% at control sites). Probing depths remained below 4 mm in all groups, with no significant attachment loss or radiographic bone resorption. The risk of bias varied between studies included in this review. GRADE assessment indicated moderate certainty of evidence for survival, marginal adaptation, periodontal outcomes, and complications, and low certainty for secondary caries and postoperative sensitivity.

Current clinical evidence supports the use of adhesive polymer-based materials for DME, demonstrating predictable outcomes in the restoration of teeth with deep proximal margins. Despite differences in polymer composition and polymerization characteristics, no clear superiority among materials was identified. Nevertheless, the limited number of randomized trials and methodological heterogeneity highlight the need for well-designed long-term studies to better understand the influence of polymer-related properties on clinical outcomes.

identifier CRD420261350880.