Comparative clinical evaluation of correct anatomic contour and tight contact in Class II direct composite restoration using two newer contact forming instruments.

Comparative clinical evaluation of correct anatomic contour and tight contact in Class II direct composite restoration using two newer contact forming instruments.

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2. Comparative clinical evaluation of correct anatomic contour and tight contact in Class II direct composite restoration using two newer contact forming instruments. 2

3. CONTENTS Introduction​ Aim Null hypothesis Materials and methods ​Statistical analysis Results ​Discussion ​ Conclusion References 3

4. INTRODUCTION Dental caries demineralization and destruction Class II cavity preparation and restoration are among the most challenging procedures for clinicians. ( A ) Preoperative image of 24; ( B ) Preoperative radiographic image of 24 ( K ) Postoperative bitewing radiograph; ( L ) Postoperative image Yu OY, Zaeneldin AM, Hamama HHH, Mei ML, Patel N, Chu CH. Conservative Composite Resin Restoration for Proximal Caries-Two Case Reports. Clin Cosmet Investig Dent. 2020 Oct 8;12:415-422. doi : 10.2147/CCIDE.S270453. PMID: 33116910; PMCID: PMC7549752. 4

5. Recreating correct anatomical contour and ensuring appropriate proximal contact tightness are crucial for the health of the periodontal apparatus. Patras, Michael & Doukoudakis , S. (2012). Class II Composite Restorations and Proximal Concavities: Clinical Management of Proximal Concavities.. Operative dentistry. 38. 10.2341/11-224-T. 5

6. Key elements in restoring a Class II cavity composite restoration include: Proper marginal adaptation . Anatomically correct contour . Tight contact area. Patras, Michael & Doukoudakis , S. (2012). Class II Composite Restorations and Proximal Concavities: Clinical Management of Proximal Concavities.. Operative dentistry. 38. 10.2341/11-224-T. 6

7. Inadequate contact and contour interproximally can lead to: Food impaction, contributing to periodontal disease and recurrent caries. Tooth movement and dental arch instability. AlTowayan , Sarah AbdulRahman . "The Prevalence of Overhanging Restorations, Effects and Prevention."  Journal of International Dental and Medical Research  16.3 (2023): 1342-1347. 7

8. Eating on one side can lead to: Imbalanced occlusion . Symptoms of masticatory pain, termed “neurological switching.” The pursuit of better contact and contour formation in Class II restorations has resulted in the development of specialized instruments called contact formers . 8

9. Two notable instruments are: LM Arte Contact – features transparent cone-shaped tips . Contact Gold Instrument by TDV Company . Advantage of enhanced light curing : as light passes through their transparent tips. Alonso V, Caserio M, Darriba IL. Use of Transparent Tips for Obtaining Tight Proximal Contacts in Direct Class II Composite Resin Restorations. Oper Dent. 2019 Sep/Oct;44(5):446-451. doi : 10.2341/17-112-T. Epub 2019 May 14. PMID: 31084531. 9

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11. AIM The study was undertaken to evaluate proximal contact tightness and contours using two newer contact-forming systems. 11

12. Null hypothesis The null hypothesis stated that there would be no difference in obtaining ideal proximal contacts and contours in Class II composite restoration using the LM Arte Contact forming instrument and the TDV contact gold instrument. 12

13. MATERIALS AND METHODS The study was a triple-blind randomized clinical trial . It adhered to the Consolidated Standards of Reporting Trials (CONSORT) guidelines. 13

14. Inclusion Criteria: Age range : Participants between 18 and 60 years who signed a consent form . Teeth characteristics : Class II carious lesions (mild to moderately deep) with diagnosis of reversible pulpitis . Normal response to cold and electric pulp tests . Secondary decay and old fractured restorations involving proximal surfaces. Teeth in normal occlusion. 14

15. Radiographic findings : Radiolucency involving enamel and dentin. Presence of sound dentin between the radiolucency and the pulp chamber. Exclusion Criteria: Patients with poor oral hygiene . Severe or chronic apical periodontitis . Pregnant or lactating women . Teeth with visible cracks intended for use as abutments. 15

16. Follow-up study adjustment : To account for a 20% dropout rate , the sample size was increased to 60 participants . 16

17. Randomization process : Random sequences were generated using computer randomization via randomizer.org . The randomization code was recorded and decoded only at the study's conclusion. Blinding : Two blinded evaluators were trained and calibrated for the study. 17

18. Clinical Procedure Examinations : Teeth with mild-to-moderate Class II caries and no pulpal involvement were selected for treatment. (a) Preoperative clinical picture 18

19. Radiographic technique : Intraoral periapical and bitewing radiographs were taken. The long cone paralleling approach was used for radiographic accuracy. (b) Bitewing radiograph 19

20. Restorative Procedure Pre-Restorative Steps: Tooth surface preparation : Dental prophylaxis and polishing were performed using a slow-speed contra-angled handpiece , a rubber cup , and a pumice slurry . 20

21. A composite button technique was employed for accurate shade matching: Composite shades ( enamel and body , Genial, GC, Europe) were applied to the tooth without bonding agents and cured. A black-and-white (monochrome portrait) shot was taken to identify the shade that best blended with the tooth. 2. Shade selection : Both an image (Canon EOS 1200D DSLR) and clinical examination were used. 21

22. Cavity Preparation: Prewedging : A metal fin (Fender Wedge, Directa AB) was inserted into the interproximal gap using bent mosquito forceps to protect adjacent teeth. 22

23. Accessing damaged dentin : Teeth were prepared using a spherical diamond drill at high speed. Diseased dentin was removed using: Dental spoon excavators (Hu- Friedy , Rockwell, Chicago). Carbide burs at slow speed. (c) Caries excavation followed by cavity preparation 23

24. 5. Caries detection : Caries detector dye (Kuraray, Okayama, Japan) was applied to ensure the removal of all residual caries. 6. Isolation : A rubber dam clamp was used for quadrant isolation. 24

25. 8. Matrix Placement: The sectional matrix band ( Palodent ) and a retainer were placed using the single wedge technique . 7. Pulp Protection: Light-cured calcium hydroxide was applied for pulp protection if necessary. 25

26. 9. Etching and Bonding: Selective enamel etching was performed. Bonding agent (Solare Universal Bond, GC, Japan) was applied to enamel and dentinal walls for 20 seconds and light-cured. (d) Selective etching, (e) Application of bonding agent 26

27. Group A: A nanohybrid composite resin (Solar X, GC, Europe) was applied to the cavity base. LM Arte Contact Former : Used to create proximal contact, available in four sizes (ES, S, M, L). LM- MultiHolder PK II was used to transport the tip based on cavity size. Lateral pressure ensured the matrix band adaptation to the adjacent tooth. (f) Proximal contact build‑up by contact forming instrument 27

28. Excess occlusal material was removed, converting the Class II cavity to a Class I restoration . Curing was done for 20 seconds through the transparent contact former tip . (g) LM arte contact forming instrument 28

29. (h) postoperative photograph ( i ) postoperative bitewing 29

30. Group B: TDV Contact + Gold Former was used for proximal contact Both groups restored the Class I cavity using an incremental cusp-by-cusp addition of nanohybrid resin composite in body shade. (c and d) Proximal wall build‑up by the design village (TDV) contact former 30

31. Before applying the final enamel layer: Shade tint application was performed using Kolor + Plus Resin Color Modifier (Kerr, California, USA). The final curing was completed with glycerin application to remove the oxygen inhibition layer . ( i ) TDV Instrument 31

32. Finishing and Polishing: The standard finishing and polishing regimen was carried out using the Shofu Super Snap Rainbow Kit (India). (f) Postcomposite restoration (h) postoperative radiograph 32

33. Occlusion Check: Occlusion was checked using the progressive color transfer concept: Articulating papers with thicknesses of 15 µm were used. Marked areas were then reduced using finishing diamond burs . Curing Light: The GC D Light Duo (Tokyo, Japan) was used for curing during the study. The light intensity was regularly checked and maintained at 1400 mW /cm² to ensure optimal curing. 33

34. Proximal contact was assessed using specific criteria. 34

35. Follow-up and Data Collection: Both groups were evaluated at baseline , 6 months , and 1 year . Statistical Analysis: Data were analyzed using the paired t-test in SPSS version 18.0 (IBM SPSS Inc, Chicago, IL). 35

36. RESULTS 36

37. Gingival index: Group B > Group A Pocket depth: 37

38. 3. Interproximal contacts: 4. Overhangs: 38

39. Outcomes: 39

40. DISCUSSION The study failed to reject the null hypothesis , meaning there was no significant difference between the two proximal contact-creating instruments evaluated: LM Arte Contact-Forming Instrument . TDV Contact-Gold Instrument . 40

41. Randomization and Allocation : Teeth were divided into two groups through computer randomization to minimize selection bias. Composite Resin Application : Adapt closely to the walls of the proximal box, ensuring a proper seal and reducing void formation. Efficient, requiring less time than traditional methods. Clinical Procedure Highlights: 41

42. Advantages: Tight proximal contacts Excellent anatomical shape Ease of matrix band placement Transparent curing tip Limitations : Extensively damaged teeth 42

43. Rationale for the Approach: By using instruments that combine contact formation with curing capabilities, it enhances the precision and reliability of results. The lateral pressure technique minimizes void development. The anatomical accuracy achieved improves not only the function but also the long-term health of the surrounding periodontium. 43

44. Implications for Practice: LM Arte Contact-Former may be ideal for smaller, less complex restorations. TDV Contact-Gold Former could be more versatile due to its angular options for mesial and distal applications. It is manufactured by the TDV Company . 44

45. Kit Features: It includes two instruments : One for moderately deep cavities . Another for extensive cavities . Each instrument has two extremities , designed for use in: Mesial cavities . Distal cavities . 45

46. Proximal Contact Assessment: Bitewing radiographs were used for assessing proximal contacts. Effective in detecting and estimating carious lesions . Prevented overlap of contact areas . Cost-effective. 46

47. Composite Placement Technique: Incremental placement technique using Nanohybrid composites Reduced the risk of polymerization shrinkage , compared to the condensable technique . Adhesion mechanism : Adhered through chemomechanical interlocking. Resin diffusion into demineralized enamel and partially demineralized dentin . Resulted in good retention and outcomes. 47

48. Posterior Resin Composite Restorations: Posterior resin composite restorations have become widely used and reliable in the past decade. Minimally invasive approach to dental treatment. Advances in resin composite filler and resin technology . The need for alternatives to amalgam due to concerns over mercury toxicity . 48

49. No Significant Differences Observed : At baseline , 6 months , and 1-year follow-up between the two groups in: 49

50. Possible Explanations for Similar Results : Restoration was performed by a single operator . The same restorative material and method of placement were used for both groups. Similar matrix systems ( sectional matrix) and wedge placement techniques contributed to the lack of significant difference in overhangs. 50

51. Karim M. et al has conducted a study t o assess biological changes in proximal contact tightness (PCT) in class II direct composite restorations and the adjacent teeth by applying sectional matrix system along with different contact forming instruments. Methods: 72 direct compound class II composite restorations were performed in patients aged 18-40 years and divided into 4 groups: M.abbassy , Karim & Elmahy , Waleed & Holiel , Ahmed. (2023). Evaluation of the proximal contact tightness in class II resin composite restorations using different contact forming instruments: a 1-year randomized controlled clinical trial. BMC Oral Health. 23. 10.1186/s12903-023-03462-5. 51

52. M.abbassy , Karim & Elmahy , Waleed & Holiel , Ahmed. (2023). Evaluation of the proximal contact tightness in class II resin composite restorations using different contact forming instruments: a 1-year randomized controlled clinical trial. BMC Oral Health. 23. 10.1186/s12903-023-03462-5. GROUP 1 Palodent GROUP 2 Trimax 52

53. M.abbassy , Karim & Elmahy , Waleed & Holiel , Ahmed. (2023). Evaluation of the proximal contact tightness in class II resin composite restorations using different contact forming instruments: a 1-year randomized controlled clinical trial. BMC Oral Health. 23. 10.1186/s12903-023-03462-5. GROUP 3 PerForm GROUP 4 Contact pro 53

54. Results: Contact forming instruments combined with Palodent plus sectional matrix system achieved better PCT. Trimax > other groups. Conclusions : Using Trimax system provided the tightest proximal contacts. M.abbassy , Karim & Elmahy , Waleed & Holiel , Ahmed. (2023). Evaluation of the proximal contact tightness in class II resin composite restorations using different contact forming instruments: a 1-year randomized controlled clinical trial. BMC Oral Health. 23. 10.1186/s12903-023-03462-5. All contact forming instruments were used along with Palodent plus matrix system.  54

55. Alonso et al conducted the study to describe the clinical technique of using the transparent tips of the LM Contact Former system in direct Class II composite resin restorations using noncontoured circumferential matrix bands. With this technique, the composite resin is pressed with the tip, which adapts intimately to the walls of the proximal box. Alonso, V., M. Caserio, and I. L. Darriba . "Use of transparent tips for obtaining tight proximal contacts in direct class II composite resin restorations."  Operative Dentistry  44.5 (2019): 446-451. 55

56. Alonso, V., M. Caserio, and I. L. Darriba . "Use of transparent tips for obtaining tight proximal contacts in direct class II composite resin restorations."  Operative Dentistry  44.5 (2019): 446-451. (a) Prewedging is done placing thick wedge with a metal fin in the interproximal space to separate protect the adjacent tooth (b) The enamel without dentin support at the cavity floor is removed with a cylindrical bur that cuts only on the flat end. (c) The largest possible tip of LMContact Former that can be introduced into the cavity is selected. (d) This cavity is filled with bulk-fill flowable composite until the last 2-mm occlusal layer that is restored with a micro-hybrid composite resin. 56

57. Kumari S, Raghu R, Shetty A, Rajasekhara S, Padmini SD. Morphological assessment of the surface profile, mesiodistal diameter, and contact tightness of Class II composite restorations using three matrix systems: An in vitro study. J Conserv Dent 2023;26:6772. Suchitra Kumari et al conducted the study to evaluate the proximal contact area in Class II composite restorations using three matrix systems based on morphological analysis, mesiodistal (M‑D) diameter and contact tightness. Methods: A standardized DO cavity was prepared in 30 plastic molar teeth. They were divided into three groups and restored using Tetric N‑Ceram composite material and three matrix systems – Saddle matrix , Palodent system , and Palodent Plus system . 57

58. The quality of proximal contacts was assessed by measuring the maximum mesiodistal diameter (a) Occlusal-third, (b) Middle-third using a digital caliper tightness of the proximal contact area using a standardized metal blade (30 m) Kumari S, Raghu R, Shetty A, Rajasekhara S, Padmini SD. Morphological assessment of the surface profile, mesiodistal diameter, and contact tightness of Class II composite restorations using three matrix systems: An in vitro study. J Conserv Dent 2023;26:6772. 58

59. Results: ` Palodent Plus system = Palodent system > Saddle matrix. Conclusion: Palodent Plus and Palodent sectional matrix systems showed nearly similar performance in terms of proximal contact tightness, proximal contour, and overhangs of the restorations while the Saddle matrix demonstrated poor results. Kumari S, Raghu R, Shetty A, Rajasekhara S, Padmini SD. Morphological assessment of the surface profile, mesiodistal diameter, and contact tightness of Class II composite restorations using three matrix systems: An in vitro study. J Conserv Dent 2023;26:6772. 59

60. LIMITATIONS Long-term clinical experiments with a larger sample size. Use of different matrix systems. This emphasizes the effectiveness of the current approach while acknowledging areas for further research. 60

61. CONCLUSION Within the limitations of the study, we can conclude that the clinical performance of composite restoration using the LM Arte Contact Forming Instrument has a slight edge over the TDV Gold Contact Forming Instrument . 61

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