Discussion
bone loss, lateral papillary compression, fracture, caries, tightness, periodontium, tooth
BONE LOSS, IMPACTION, INFLAMMATION, GINGIVAL BLEEDING, CARIES, ADHESION, PLAQUE, PATHOLOGY, CREST
The first and most basic goal of restorative dentistry is to preserve the tooth structure. However, for long-term restoration survival, the periodontium should be healthy, or vice versa [Restorative management of the black triangle represents almost 67% of the adult population over the age of 20 years [In the current trial, teeth were assigned into intervention or control groups using simple randomization 1: 1 with the help of computer software (As ascertained by Schulz, (2001) [This step ensures standards of quality, improves performance, and provides credibility of the study.. Clinical trials must go through a rigorous process before being accepted. The investigation was carried out with the acceptance of the institutional review board of the Faculty of Dentistry, Cairo University, as it is recommended that before a clinical trial can take place, a group of researchers who are not participating in the trial should first approve the protocol, the overall plan, and all phases of the trial. This is called an independent scientific review or peer review.As hybrid resin composites were confirmed to have better overall performance in terms of esthetics and fracture than microfilled resin composites [Kim and Clark, (2017) [The use of a clear mylar strip also known as celluloid matrix is the most popular matrix technique for proximo-incisal defects as the mylar strip technique originated with the beginning history of the resin restorations, where bulk material had to be placed because of the short working time of chemically cured resin materials. While for light curing materials, provided the clinicians extended controlled working time allowing for incremental insertion technique. Hence the Celluloid matrix is simple, available, cheap, and there is no need for special equipment considered to be their main advantages [Restoring the correct emergence profile of the teeth with adequate proximal contact is considered as on the the greatest challenges for clinicians. Thus, several studies assessed different materials and techniques in order to properly establishing the tightness and quality of the proximal contact, and balancing the teeth as well as, the health of the periodontium [In this clinical trial, in order to obtain a standardized process it was very important to standardize the several variables as patient selection by following the inclusion criteria and patient preparation even an air abrasion step was done for both groups to exclude this variable.In order to minimize cofounders and eliminate selection bias black triangles were selected in maxillary teeth in the esthetic zone due to increased variability in form, contour, and arrangement of teeth between upper and lower arch to reflect restorative procedure and interdental papillary regeneration., Cl III loss of papillary height according to Nordland and Tarnow classification in maxillary teeth in esthetic zone was excluded because this method is unpredictable when a large volume of tissue is missing, this was in accordance to Parihar, (2018) [All the restorative procedures were carried with magnification loops as magnification establishes a squared, instead of a linear, relationship between magnification powers and "picture elements" or "pixels" of information. In other words, clinicians operating at 3.5 × see 10 times more visual information than with the naked eye, and clinicians working at 10 × see 100 times more [Rubber dam isolation allow for retraction of soft-tissue and papilla compression. Furthermore it protects the soft tissues during sandblasting process to remove sticky biofilm. For lateral compression to existing papillae, a minimum subgingival restorative contour of 1.0- to 1.5-mm is required. This lateral papillary compression mold the papilla to fill the embrasure space not filled by resin composite [In this clinical trial, in order to restore the proximal profile as a restorative approach for management of the black triangle two techniques were established and compared, the conventional celluloid matrix technique and bioclear matrix system. According to the conventional celluloid matrix technique, the matrix stripAs the celluloid matrix is flaccid, its manipulation was not easy. Care was taken not to pull the strip too tightly, to prevent under contouring of restoration. It was initially over-contoured in order to facilitate finishing to an ideal contour. The narrowed Mylar strip was useful for controlling emergence and gingival contour. Also, it was easy to access resin instruments and improved visibility following Azzaldeen et al., (2014) [Intervention group using bioclear matrix was performed according to manufacturer instructions to guarantee the standardization of the procedure. Before the application of the rubber dam application, a critical step was performed where the contacts were sanded in order to lighten the tension at the areas of contacts and allow full seating of the matrices. Moreover, contacts sanding allow for removal of the soft and sticky biofilm present around the contact area that is not removed by etching process as well as the fluoride pellicle on the tooth for ideal bonding performance. Flowable and paste resin composites were heated to 70 cThe inactive matrix used on the adjacent teeth “Shield matrix” was used to protect and maintain the embrasure shape as well as keep the adjacent tooth from resin contamination during injection molding. The Shield matrix was used after a while as active one [The anatomical contour of the matrix allows for a smooth cervical curvature, leading to proper direct resin composite designs that are highly conductive to papilla regeneration. This is due to two inherent characteristics. The first feature is the ability to use the papilla like a wedging force instead of a traditional wedge. A traditional wedge shapes the cervical into a flat shape. Flat cervical shapes lack the static pressure required for papilla regeneration. The second distinguishing feature is an anatomically correct shape with exaggerated palatal, interproximal, and facial surfaces. This allows the clinician to simply remove the matrix following photo-polymerization, with minimum or even no interproximal finishing. Tissue health can be excellent even with a very round embrasure form when the finish is extremely smooth and there is no gingival ledge. This modern perspective on cervical curvature contrasts sharply with the outdated belief that prosthetic and restorative embrasures should be flat [FDI criteria were used in this trial to clinically evaluate the different outcomes of the study, as FDI criteria were described as being practical, relevant, and standardized, making comparisons between parameters easier. Investigators should continue to use them to improve the standardization of their clinical judgments and to allow comparisons with other studies. Photographs were provided to both examiners as reference tools to illustrate scoring at each criterion [This was a randomized clinical trial, which is typically regarded as the paradigm for clinical trials and provides the highest level of evidence. As cited by Hopewell et al. (2010) [In the present study, the null hypothesis was accepted for the outcomes: proximal anatomical form, Esthetic anatomical form, periodontal response, and marginal staining, phonetics and food impaction. However it was rejected for the outcomes: radiographic marginal integrity and marginal adaptation. The results of the clinical evaluation of proximal anatomical form and food impaction revealed that all cases in both groups were successful, with no statistically significant difference. In the present study, group A (celluloid matrix) showed successful aesthetic performance. This might be attributed to proper handling of the matrix and steady flow of the materials as the celluloid matrix was inserted between the teeth down into the gingival sulcus and checked for inciso-gingival length to ensure proper resin composite material construction involving the entire emergence profile of the tooth. The findings were consistent with the previous investigations of Ergin et al., (2018) [In terms of the evaluation of aesthetic anatomical form, the difference found between celluloid matrix and bioclear matrix was not statistically significant. In the present study, the majority of cases in group A (celluloid matrix) reported a score of (3) at all intervals, denoting that form deviates from normal but is aesthetically accepted, while most of the cases in group B (bioclear matrix) had a score of (2), denoting form only slightly deviates from the normal. According to Bansal et al., (2019) [Regarding the periodontal response, at T0 (immediately after restoration), the majority of the cases in the celluloid matrix group and all the cases in bioclear matrix group reported a score of (1), denoting no plaque and no inflammation. At T6 (6 months), the majority of the cases in the celluloid matrix group either reported a score of (2), denoting little plaque and no inflammation, or a score of (3), denoting plaque accumulation or acceptable gingival bleeding, while most of the cases in bioclear matrix group had scored (2). At T12 (12 months), the majority of the cases in both groups reported a score of (3). These results were in accordance with Kim and Clark. (2017) [At all-time intervals, the difference in periodontal response between the celluloid matrix and bioclear matrix groups was not statistically significant. However, there was a statistically significant difference between scores measured at different follow-up intervals. At T0 (immediately after restoration), it was significantly different from other intervals. This might be attributed to placing the restorations' margins slightly below the gingival crest to achieve a natural appearance, precise application of composite resin material, resin composite excess removal, polishing of all resin composite surfaces may have reduced their impact on adjacent oral tissues, the teeth were isolated using a rubber dam to allow for better visualization and tissue retraction, which would aid in relating the restoration contour to the proximal tissues in a more periodontium-friendly approach; and post-operative instruction to the participants to follow oral hygiene measures strictly with the prohibition of using toothpicks.Regarding the marginal staining, at TAt all-time intervals, the difference in marginal staining between the celluloid matrix and bioclear matrix groups was not statistically significant. This was attributed to the absence of bone loss, no overhang or gap formation, good periodontal condition, no signs and symptoms, no cervical caries, no roughness, and immediate flash removal. This finding has been attributed to the fact that two groups received the same resin composite and finishing and polishing protocol with the same operator.this result was following Mattar et al., (2016) [However, there was a statistically significant difference between scores measured at different follow-up intervals. In celluloid matrix group, at TIn terms of the marginal adaptation, there was a statistically significant difference between both groups’ at all follow-up intervals. However, there was no statistically significant difference between the scores measured at different follow-up intervals. The majority of the cases in group A (celluloid matrix) and all the cases in group B (bioclear matrix) reported a score of (1), denoting harmonious outline, no gaps, and no discoloration was found. At TRegarding the radiographic marginal integrity results, there was a statistically significant difference between both groups’ at all follow-up intervals. However, there was no statistically significant difference between the scores measured at different follow-up intervals for both groups. These results came in agreement with Clark and Kim. (2017) [The majority of the cases in group A (celluloid matrix) reported either a score of (2.1), denoting acceptable excess present, or (3.3), denoting poor radio-opacity of the filling material, and all the cases in group B (bioclear matrix) reported a score of (1), denoting no pathology harmonious transition between restoration and tooth. This was attributed to the flaccid nature of the celluloid matrix, unlike the appropriate anatomic shape with exaggerated palatal, interproximal and facial surfaces and the self-stabilizing design of the bioclear matrix. The Heated flowable and paste resin composite material fills the mold in the form of bioclear matrix perfectly with a nice transition to the tooth structure due to its viscosity. It can thus be molded in a very thin layer, eliminating the need for tooth preparation in most cases and preserving the entire healthy tooth structure, as in the presented case. To be more specific, because it is a completely additive technique, only the etch-and-rinse protocol is required for effective adhesion [As the science of phonetics implies how sounds and speech are articulated, gingival tissue should cover the teeth's roots, but if exposure occurs, particularly interproximal, speech may be affected as air goes through the missed papilla space [Within the limitations of the present research, it could be considered that the restorative management of the black triangle with both protocols meets the following objectives: superior aesthetic and good marginal adaptation; suitable biological properties; enhanced subjective and objective appearance of the treated teeth; and adequate survival time. Thus the null hypothesis was accepted for the outcomes: proximal anatomical form, Esthetic anatomical form, periodontal response, and marginal staining, phonetics and food impaction. However it was rejected for the outcomes: radiographic marginal integrity and marginal adaptation. Both techniques are clinically relevant and were almost equally successful, however they are depending on the operator skills. Thus some clinical recommendation could be addressed as guide for clinicians:For celluloid matrix technique, to achieve the ideal emergence profile, contact point, and correct contour and to prevent overhanging, ensure cervical strip closure in the apical direction.For bioclear matrix technique, respect the size of the matrix (color) in accordance with the gauge for an optimum result.