Case StudiesSeptodont

CollectionNo. 06 - October 2013

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EditorialSince its foundation Septodont has developed, manufacturedand distributed a wide range of high quality products fordental professionals.

Septodont recently innovated in the field of gingival prepa-ration, composites and dentine care with the introductionof Racegel, the N’Durance® line and Biodentine™, whichare appreciated by clinicians around the globe.

Septodont created the ‘Septodont Case Studies Collection’to share their experience and the benefits of using theseinnovations in your daily practice.This Collection consists in a series of case reports and ispublished on a regular basis.

The sixth issue is dedicated to three of these innovations:Racegel, a unique reversible thermo-gelifiable gel forgingival preparation that creates a dry and clean environmentfor high quality impressions.N’Durance®, the first universal composite based on ourexclusive Nano-Dimer Technology. N’Durance® uniquecombination of low shrinkage and high conversion offersextra biocompatibility and durability to your restorations. Biodentine™ , the first biocompatible and bioactive dentinreplacement material. Biodentine™ uniqueness not only liesin its innovative bioactive and ‘pulp-protective’ chemistry,but also in its universal application, both in the crown andin the root.

Racegel : Gel Retraction MaterialLeonard A. Hess 04

A four-year prospective study of the use ofN’Durance composite, a nano-hybrid resinHolli Cherelle Riter

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The direct application of Biodentine™under indirect ceramic restorationC. Boutsiouki, Prof K. Tolidis, Prof P. Gerasimou

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Apicoectomy treated with an activebiosilicate cement: Biodentine™Dr. César A. Gallardo Gutiérrez

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Content

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Racegel : Gel Retraction MaterialIncreasing the success and predictability of fixed prosthodontic

Leonard A. Hess, DDSPrivate Practice, Monroe, North Carolina, USA

IntroductionIn fixed prosthodontics, clinically acceptableimpressions are an absolute necessity (Fig. 1).The laboratory fabricating the restoration is limitedin its final quality by the quality of the incomingimpression. The unfortunate reality is that mostimpressions are clinically unacceptable.1

Some of the most common errors seen in impres-sions include tears, bubbles, voids, debrisentrapment, tray burnthrough, material/tray sepa-ration, and lack of catalyzation of the material.2

Unfortunately, many of these errors are mostevident at the restorative margin. Any lack ofdetail at the margin forces the laboratory technicianto guess during die trimming. This area is highly

susceptible to the collection of blood, debris,and lymphatic exudate. Considering the limitedhydrophilic nature of most impression materials,issues can quickly compound.The most predictable way to obtain a qualityimpression is to start with healthy tissue. Pre-restorative planning should include any necessaryperiodontal treatment, patient hygiene instruction,and caries control.3 Different options exist to aidin tissue management. These would include theuse of retraction cord, chemical hemostaticagents, a soft tissue laser, and tissue gels orpastes, either alone or in various combinations.Attention should also be given to the position ofthe osseous crest and the compensating gingivalbiotype. In a normal crest relationship, the depthfrom the gingival margin to the bony crest is3 mm to 4 mm apart. A distance greater thanthis would indicate a low-crest relationship.Depths of less than 3 mm would be indicative ofa high-crest relationship.4

Tissue with a low-crest position would be lesssupported, more flaccid, and more prone torecession as a result of trauma or over-manipu-lation. Tissue associated with high crestal boneis usually thicker, more fibrous, and more forgivingof damage. However, high-crest bone is at higherrisk of biologic width violations.This article will discuss impression techniquesusing a new gel retraction and hemostatic aidcalled Racegel (Fig. 2).

Fig. 1: An ideal indirect restoration impression. The material isvoid-free, clear of debris, and exhibits clean capture of thepreparation margins.

Fig. 2: Racegel is dispensed from a single-barrel syringe. It iscolored to allow easy visualization in placement and to aid inverification of its removal.

Case Report no.1This posterior crown is a common example of alow crest and deep sulcus restorative situation(Fig. 3). Because of the sulcus depth, often onecord is not adequate to fully displace the tissueand obtain a quality impression. Instead of trau-matizing the tissue with two cords, one smallcord was placed and then Racegel was injectedinto the sulcus. This provided the necessaryretraction and hemostasis.All-ceramic preparation margin designs will oftenbe at the level of the gingival margin (Fig. 4).The premolar seen in this figure, which has anormal gingival biotype, can be readied forimpression with Racegel as the sole source ofretraction.

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The features of the Racegel include:• Thermodynamic chemistry that provides increa-sing viscosity in the oral cavity. The thermaleffect is reversed when rinsed with water forease of removal.5

• 25% aluminum chloride for optimal control ofbleeding and crevicular fluid.

• An orange color for easy viewing during place-ment and for confirming complete removal.

• Can be used in conjunction with cord or simplecontrol of gingival bleeding.

Fig. 3: In cases with a thinner gingival biotype, Racegel can beused as the sole source of hemostasis and tissue retraction.

Fig. 4: In this case Racegel was being used in conjunction with apacked cord to control gingival bleeding and to aid in tissueretraction.

Fig. 5: In this multi-unit case, Racegel was used in conjunctionwith cord to control interproximal bleeding.

Fig. 6: The final impression from the case.

Fig. 7: The final lithium-disilicate veneer restorations. Note thehealthy tissue response associated with properly fittingrestorations.

Case Report no.2Preoperatively, this case had generalized inter-proximal decay and decalcification (Fig. 5), whichresulted in residual interproximal inflammation andbleeding at the preparation visit. Dry cords wereplaced in the sulcus, and Racegel was placed onthe bleeding areas. By controlling the tissue andobtaining a high-quality impression (Fig. 6), properlyfitting restorations were created that allowedoptimal health postoperatively (Fig. 7).

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Case Report no.3This anterior crown preparation was associatedwith a thin gingival biotype and low bone crest.To keep tissue trauma to a minimum, Racegelwas used as the only source of retraction (Fig. 8).After 2 minutes of setting, the material waseasily rinsed away, leaving a clearly exposedmargin (Fig. 9). The resulting impression hadcrisp 360º margins and captured past the marginend point (Fig. 10).

ConclusionsThere is no doubt that modern dental materialscan improve the efficiency of restorative care.However, there is no replacement for goodclinical judgment and proper diagnosis. Onlywhen these types of materials are applied in theproper circumstances will predictability anduncompromised quality complement the effi-ciency gained.

Fig. 9: The Racegel was rinsed away with no residue, leaving adry, clearly exposed margin.

Fig. 8: An anterior crown preparation. This tooth had an averagegingival biotype, which allowed the use of Racegel as the solesource of gingival retraction.

Fig. 10: The final impression. Note the 360º marginal capture.

Originally published in Inside Dentistry ©2011 to Aegis Publications, LLC. All rights reserved.Reprinted with permission from the publishers.

References

01. Samet N, Shohat M, Livny A, et al. A clinical evaluation of fixed partial denture impressions. J ProsthetDent. 2005;94(2):112-117.

02. Hess L. Creating restorative success with clinical zirconia. Inside Dentistry. 2006;2(8):62-66.

03. Hess L. The biologic and restorative interface. Contemporary Esthetics and Restorative Practice.2005;9(3):46-51.

04. Kois JC, Vakay RT. Relationship of the periodontium to impression procedures. Compend Cont Educ Dent.2000; 21(8):684-692.

05. Data on file. Laboratory Matiere of Systems Complexes. 2008; University of Paris.

Author: Leonard A. Hess, DDSPrivate Practice Monroe, North Carolina Associate FacultyThe Dawson AcademySt. Petersburg, Florida

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Composite filling material is intended to replacemissing tooth structure by replicating the lookand function of natural tooth structure as closeas possible. A desirable composite should behighly esthetic, and functionally strong. In addi-tion, good handling characteristics are importantfor ease of placement. A highly radiopaquecomposite is beneficial, as it enhances theoperator’s ability to differentiate the compositefrom tooth structure or caries on a radiograph.Finding a composite that satisfies the need foresthetics and durability is a goal for moderndentistry. Changing the quality and size of thefiller particles in a composite can affect theesthetic quality and the mechanical property of acomposite (Narhi, 2003). Nano- and nano-hybrid

filler particles were developed with the goal ofincreasing strength of the composite, and impro-ving the esthetics by decreasing the filler size(Ilie N R. A., 2011). The small size of the nanoparticles, ranging from 1 to 100 nm in diameter,has been reported to contribute to superiormechanical properties, such as low polymerizationshrinkage, high flexural strength and low abrasion(Papadogiannis D.Y., 2008). Smaller particles ina composite are shown to have better wearresistance as well as a higher polishablility (VanDijken J., 2011) (Palaniappan S, 2010).Septodont, Confi-Dental Division, released thecomposite N’Durance® that proposes to combinehigh esthetics with strength and durability bycombining nano-hybrid fillers with a new dimer

A four-year prospective study ofthe use of N’Durance® composite, a nano-hybrid resin Holli Cherelle Riter DDSLoma Linda University School of Dentistry - California, USA

The purpose of this study was to evaluate the clinical performance of a new compositeresin material, N’Durance®, in anterior teeth. Class III, IV, V, diastema closures and facialresin veneers were placed by one operator in the dentitions of the patients recruited tothe study. Fifty-two restorations in 30 patients were originally placed, and at the 4-yearrecall, 26 restorations in 15 patients were evaluated. The results were collected usingmodified USPHS criteria. The results at four years showed that the majority of the USPHScategories were rated 100% Alpha at the 4-year evaluation, with the exception of colormatch having 73% Alpha, marginal adaptation 77% Alpha, and Polishability 96% Alpha,indicating satisfactory esthetic qualities and adequate strength and a high retention ofN’Durance® composite.

Introduction

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acid monomer technology (Bracho-Trachonis,2008). The dimer acid monomer technologyhelps to reduce shrinkage during polymerization,and it has a higher degree of monomer conver-sion (Ilie N R. A., 2011), which leads to lessuptake of water (Bracho-Trachonis, 2008) (IlieN H. R., 2011).The N’Durance® composite offers good handlingcharacteristics, having a high viscosity and lowfeeling of stickiness during placement. In addi-tion, it has a high opacity on radiographs,making it easy to differentiate it from toothstructure (Fig. 1).The purpose of this study was to evaluate theclinical performance of N’Durance® compositein anterior class III, IV, V, facial veneers anddiastema closure restorations over a four yearperiod of time. Fig. 1

Materials and MethodsA total of 52 restorations were placed in anteriorteeth throughout the anterior dentitions of 30patients by one dentist at Loma Linda UniversitySchool of Dentistry. Prior to initiation of thestudy, the protocol and the informed consentwere submitted to and approved by the Institu-tional Review Board (IRB) of Loma LindaUniversity. Written informed consent was obtainedfrom each subject prior to the placement of therestorations. Healthy adults who exhibited aneed for an anterior resin restoration wererecruited to the study. Class III, IV, V, diastemarepairs and facial veneer resins were includedin the study. All restorations were restored withN’Durance® composite resin. Pre-operative photographs and radiographs ofthe sites were taken. Shade selection was madeprior to starting the procedure using the VitapanClassical Shade Guide (Vident, Brea, CA). Eachcavity was prepared using high speed diamondburs and a conservative preparation design.Any carious tooth structure was removed usingsteel carbide round burs on a slow speed hand-piece. Isolation was achieved using cotton rollsand saliva evacuation, along with gingival cord

when needed. Rubber dams were not usedsince all the restorations were placed on anteriorteeth where saliva was well controlled. Thepreparations included etching on enamel anddentin with Gel Etchant (Kerr, Orange, CA), a37.5% phosphoric etching gel for 20 seconds,and then thoroughly rinsed with water. Theexcess water was removed. The preparationswere bonded with Opti-Bond Solo (Kerr, Orange,CA) and light cured for 20 seconds according tomanufacturer’s instructions. They were then filledwith N’Durance® resin composite with a 1-2mm incremental technique, curing each incrementfor 30 seconds. The curing light (with a minimumradiance of 500 mW/cm2) was held approximately1 mm away from the tooth surface during thelight activation (curing). The restorations werefinished with carbide finishing burs and polishedwith OptiDiscs (Kerr, Orange, CA), Jiffy PolishingPoints and Cups (Ultradent, Salt Lake City, UT)and Jiffy Composite Polishing Brushes (Ultradent,Salt Lake City, UT), as needed.Restorations were evaluated at the baseline(two weeks after placement), six months, one-year, eighteen months, two-year, three-year and

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four-year using the modified United States PublicHealth Service (USPHS) criteria (Bayne S., 2005).Anatomic form, color match, marginal adaptation,marginal discoloration, surface staining, retention,secondary caries, fracture and polishability wereevaluated for each restoration, along with softtissue health and post-operative sensitivity. Thepost-operative sensitivity data were obtainedby asking each patient to rate their sensitivity

based on a scale of 0 to 10, with 0 having nosensitivity and 10 having extreme sensitivity.Clinical photographs were taken at each of theevaluations, and a radiograph of each site wastaken at each of the year evaluations. At thefour-year follow-up, 26 restorations in 15 patientswere evaluated. The remainder of the patientswas either dropped from the study, or unable tobe located for the four-year evaluation.

Subject 1

Subject 2

Results and DiscussionThe results for the four-year evaluation ofN’Durance® composite are shown in Table 1.All of the 26 restorations that were evaluatedwere determined to have an Alpha rating in thecategories of Anatomic Form, Retention, MarginalDiscrepancy, Surface Staining, Secondary Cariesand Fracture. Nineteen of the restorations wererated an Alpha in the Color Match category andseven Bravo, showing a slight shade differen-tiation. The color of the material had not changedsince the Baseline. Six of the 26 restorationswere rated a Bravo in the marginal adaptation,noting some slight discrepancy present along

the enamel margin, not deemed to require anysort of repair of the margin. The remainder wasrated Alpha for marginal adaptation. This issimilar to results seen in published comparablecomposite studies (Van Dijken J., 2011) (DukicW, 2010). There was one restoration rated as aBravo in the Polishability category, showing aless than ideally reflective surface. The rest wasrated Alpha for Polishability. The polishability ofN’Durance® composite was very high at thefour-year evaluation, and this seems to be oneof the strengths of this product.There was no reported sensitivity with the

Pre-operative situation Restoration at baseline Restoration at 4 years

Pre-operative situation Restoration at baseline Restoration at 4 years

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Baseline Four-years

Total Restorations 52 (100%) 26 (100%)

Anatomic Form (Wear)

A 52 (100%) 26 (100%)B 0 (0%) 0 (0%)C 0 (0%) 0 (0%)D 0 (0%) 0 (0%)

Color Match

A 39 (75%) 19 (73%)B 13 (25%) 7 (27%)C 0 (0%) 0 (0%)D 0 (0%) 0 (0%)

Marginal Adaptation

A 50 (96%) 20 (77%)B 2 (4%) 6 (23%)C 0 (0%) 0 (0%)D 0 (0%) 0 (0%)

RetentionA 52 (100%) 26 (100%)B 0 (0%) 0 (0%)C 0 (0%) 0 (0%)

Marginal Discoloration

A 52 (100%) 26 (100%)B 0 (0%) 0 (0%)C 0 (0%) 0 (0%)D 0 (0%) 0 (0%)

Surface StainingA 52 (100%) 26 (100%)C 0 (0%) 0 (0%)

Secondary CariesA 52 (100%) 26 (100%)C 0 (0%) 0 (0%)

FractureA 52 (100%) 26 (100%)B 0 (0%) 0 (0%)C 0 (0%) 0 (0%)

Polishability

A 52 (100%) 25 (96%)B 0 (0%) 1 (4%)C 0 (0%) 0 (0%)D 0 (0%) 0 (0%)

Table 1 – Clinical Results of Restorationsat Baseline and Four-years

N’Durance® composite restorations at any ofthe evaluations. In addition, no significant gingivalinflammation was observed in relation to theplacement of the composite. In the patientsthat did exhibit gingival inflammation, this wasa general condition in the patient’s mouth, andnot isolated to the areas around the compositerestoration.Composites fail for a multitude of reasons,among these are recurrent caries and fracture

(Watanabe H, 2008). Many studies have beendone evaluating the strength and clinical successof composites both in anterior and posteriorteeth. Although we are evaluating only anteriorteeth in this study, the reasons for failure aresimilar wherever the composite is placed. Thereis an indication that the larger the restoration,the higher the likelihood of failure (Moura F,2011). In particular for anterior teeth it has beenreported that class IV composites failed at a

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higher rate than class III composite restorations(Moura F, 2011). So far at the four-year evaluation,the N’Durance® composite has shown very littleproblems when used for larger class IV restora-tions, including the larger diastema closures.Secondary caries has also been identified asone main reason for failure in previous compositestudies (Ferracane, 2013). There were no signsof any secondary caries detected in this study.There was some slightly noticeable ditchingalong the margins of a few of the restorations.No repair was needed to the margins. Marginaladaptation is highly correlated to the polymeri-zation shrinkage of a composite (Baracco B,2013). The decrease in the Alpha scores for themarginal adaptation category is similar to relatedstudies (Baracco B, 2013) (Van Dijken J., 2011).The esthetics of the N’Durance® composite wasvery high. At the four-year evaluations, the poli-shability was excellent. For all but one restoration,the polishability remained in the highest evaluationcategory, indicating a high shine replicating theenamel surface. This is one of the most pleasingcharacteristics of the N’Durance® composite.The polished surface of the restorations at thefour-year evaluation was similar to the baselineevaluations. This is likely contributed to thesmall size of the particulates, which would allow

for a higher shine. Photos of some of the resto-rations are included in this article.The handling characteristics of N’Durance®

composite are very good. The stickiness of acomposite can be manipulated by altering boththe filler content and changing the monomerformulations (Al-Sharaa K, 2003). A compositethat is too sticky when applying it can createvoids by pulling back from the preparation as itsticks to the dental placement instrument (Al-Sharaa K, 2003). N’Durance® composite has ahigh viscosity feel to it, as well as the quality ofnot sticking to the instruments during placement,so that the restoration can be easily shapedand formed.In this study, we were able to evaluate 26 of theoriginal 52 restorations that were placed. Thisis a 50% drop out rate, which appears to behigh for this type of study. Most of the droppedsubjects were due to their moving out of thearea or being unreachable. A couple of subjectswere dropped due to case selection not meetingthe study parameters; another two subjectswere withdrawn from the study due to theirtooth bleaching that occurred during the study,thus affecting the color match outcome. A higherretention rate would have been desirable butwas unachievable in this situation.

Subject 3

Subject 4

Pre-operative situation Restoration at baseline Restoration at 4 years

Pre-operative situation Restoration at baseline Restoration at 4 years

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References

01. Al-Sharaa K, W. D. (2003). Stickiness prior to setting of some light cured resin-composites. DentalMaterials, 182-187.

02. Baracco B, P. J. (2013). Two-Year Clinical Performance of a Low-Shrinkage Composite in PosteriorRestorations. Operative Dentistry .

03. Bayne S., S. G. (2005). Reprinting the classic article on USPHS evaluation methods for measuring theclinical research performance of restorative materials. Clin Oral Investig , 209-214.

04. Bracho-Trachonis, C. (2008). N'Durance nano-dimer conversion technology scientific file. Louisville,CO: Septodont, Confi-Dental Division.

05. Dukic W, D. O. (2010). Clinical Evaluation of Indirect Composite Restorations at Baseline and 36 MonthsAfter Placement. Operative Dentistry , 156-164.

06. Ferracane, J. (2013). Resin-based composite performance: Are there some things we can't predict? DentalMaterials , 51-58.

07. Ilie N, H. R. (2011). Resin composite restorative materials. Australian Dental Journal , 59-66.

08. Ilie N, R. A. (2011). Investigations towards nano-hybrid resin-based composites. Clin Oral Invest.

09. Moura F, R. A. (2011). Three-year Clinical Performance of Composite Restorations Placed byUndergraduate Dental Students. Braz Dent J , 111-116.

10. Narhi, T. (2003, 7). Anterior Z250 resin composite restorations: one-year evaluation of clinical performance.Clin Oral Invest , 241-243.

11. Palaniappan S, E. L. (2010). Three-year randomised clinical trial to evaluate the clinical performance,quantitative and qualitative wear patterns of hybrid composite restorations. Clin Oral Invest , 441-458.

12. Papadogiannis D.Y., L. R.-A. (2008). The effect of temperature on the viscoelastic properties of nano-hybridcomposites. Dental Materials , 257-266.

13. Van Dijken J., P. U. (2011). Four-year clinical evaluation of Class II nano-hybrid resin composite restorationsbonded with a one-step self-etch and a two-step etch-and-rinse adhesive. Journal of Dentistry , 16-25.

14. Watanabe H, K. S. (2008). Fracture toughness comparison of six resin composites. Dental Materials , 418-425.

Author: Holli Cherelle RiterHolli Riter is a full time faculty member at Loma Linda University School ofDentistry. She graduated from the School of Dentistry in 1998 and worked forseveral years in private practice. She joined the faculty full time as an assistantprofessor in 2005, and later joined the Center for Dental Research in 2007. Sheenjoys both working with students as they learn dentistry and working in dentalresearch, with a focus on esthetic materials. She is an active member of the

International and American Association of Dental Research, the Academy of CosmeticDentistry, and the Academy of Operative Dentistry.

ConclusionWithin the limitations of this study, it can beconcluded that, N’Durance® composite is afavored choice for anterior resin restorations,

having both high physical properties and excellentesthetics after four years.

AcknowledgementsThis study was supported by a grant from by Septodont, Inc. The author received an honorarium for writingthis paper.

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Restoring posterior teeth with missing cusps isalways a challenge. Onlay restorations are usuallystratified when greater tissue loss is observed,therefore rejecting direct restorations while stilldemanding a conservative treatment (WalmsleyAD, 2007). These clinical situations alwaysinvolve the dentin-pulp complex. In an effort toexcavate carious dentin and differentiate betweeninfected and affected dentin (Tolidis and Bout-siouki, 2012) cavity margins are sometimesplaced in close proximity with the dental pulp.The situation becomes more severe, in caseswhen estimated remaining dentin thickness issmaller than 1.5 mm and pulp protection isnecessary. Beside choosing the correct materialand technique, it is crucial that restorationmargins should not allow any microleakage,facilitating pulp healing. Beside conservativepreparation and superior esthetics, ceramiconlays offer advantages such as seal of thedentin-pulp complex, higher bond strength andreduced postoperative sensitivity (Walmsley AD,2007). Besides, marginal leakage in ceramicrestorations is minimized, due to the thin layerof resinous cement, allowing for reduced poly-

merization shrinkage or thermal volumetricchanges. Traditional pulp protection methods include theuse of liners, varnishes and bases under resto-rations, in order to insulate pulp from exteriorstimuli, allowing for self-healing process toprogress. An ideal pulp protection materialshould compensate for dentinal tissue loss,simultaneously stimulating tissue regenerationand a good pulp response. Base materials aredesigned to compensate for larger tissue loss.However, when a bioactive material was needed,calcium hydroxide was available as a liner, whichshould be followed by the placement of a basematerial, such as glass ionomer cements(Walmsley AD, 2007). Addition of Portland cementand mineral trioxide aggregate (MTA) in thedental armamentarium, has extended the capa-bilities of pulp healing. Although biocompatibility,tissue regeneration and induction of dentinbridge formation have been clarified, handlingcharacteristics of calcium-based cements arestill under invesitgation, since moisture levels,condensation technique, optimum pressureduring condensation and setting time are impor-

The direct application ofBiodentine™ under indirectceramic restorationC. Boutsiouki, Prof K. Tolidis, Prof P. GerasimouDepartment of Operative Dentistry, Aristotle University of Thessaloniki, Greece

Introduction

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Case Report

tant factors determing the clinical outcome (Raoet al. 2009). Setting time of MTA, which extendsup to more than 2 hours, makes a secondpatient visit mandatory, for the placement ofthe final restoration. There is no data in therecent literature, indicating that an indirect resto-ration can be fabricated over MTA, without themediation of a conventional base material.Biodentine™, a comparable tri-calcium silicate,has been developed as a dentine substitute indeep cavities, possesing similar mechanicalproperties with dentin, therefore superior toMTA. Biodentine™ is biocompatible and is biolo-gically active in contact with dentin, exhibingvery good results in deep carious lesions andpulp capping in adults (Biodentine™ scientificfile). The material sets in 12 minutes and can beused a long-term temporary restoration. Thanksto the comparable mechanical properties withdentin, Biodentine™ can be used under indirectrestorations, acting as a base, nonetheless follo-wing the initial manufacturer’s instructions (Shalaet al. 2012). However, handling procedure afterinitial setting has been recently revised. Bioden-tine™ was initially suggested to allow for atleast 48 hours before preparation of its surfacefor a direct or indirect restoration. If the materialhad not been fully set, the soft surface couldnot be easily prepared, the matrix would havebeen vulnerable to an acid attack (during etching)and the mechanical properties would probablydeteriorate. Recently material instructions have

been revised by the manufacturer, reccomendingsafely the immediate preparation of Biodentine™after its 12-minute set. Its superior in vitroperformance, compared with conventional basematerials (glass ionomer cements and flowablecomposite resins) under direct composite resinrestorations bonded with self-etch bondingsystem, proved that immediate restoration isharmless to the cement (Tolidis et al. 2013)(Fig. 1) and that its mechanical properties arecomparable to conventional base materials(Yapp et al. 2012). It could further be assumed,that continuation of setting process of Bioden-tine™, allows for absorption of polymerizationshrinkage stresses from the overlying compositeresin, resulting in preservation of excellentmarginal seal and minimized microleakage (Tolidiset al. 2013) (Fig. 1). The combina-tion of bothi n n o v a t i v ep rocedu res(Shala et al.2012, Tolidis etal. 2013, Yappet al. 2012) hasbeen appliedto the follo-wing casereport. A large dental tissue loss was restoredwith a ceramic restoration, directly after dentinwas substituted by Biodentine™.

Fig. 1

A 27-year-old female patient presented in thedental clinic for a routine dental examination.The patient had excellent oral hygiene and afew, minor restorations. During clinical exami-nation, special attention was given to the firstmaxillary molar, due to a Class II compositeresin restoration with bad anatomy and appea-rance and signs of secondary caries at thecervical margin (Fig. 2). Bite-wing radiographswere taken to complement the examination ofthe suspected first molar and check for initial

Fig. 2

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caries in mesial and distal areas of all posteriorteeth. Secondary caries was found in the radio-graph under the existing composite resinrestoration and restoration margins were notacceptable. Moreover the radiograph revealedan initiated osteolysis at the bone crest of thesupporting bone between the second premolarand the first molar, probably owing to an incorrectcontact point which allowed for food debrisaccumulation (Fig. 3). Therefore it was decidedto replace the restoration. Tooth vitality testing(cold) was positive. Composite resin was removed under local anes-thesia with a cylindrical high speed bur withwater spray irrigation and secondary caries wasclinically, directly confirmed. During compositeresin removal, the mesial palatinal cusp brokedue to great undermining by caries (Fig. 4).Caries was removed by means of an excavatorand a low speed round bur. At the mesial area,caries extended below the gingiva, thereforelocal gingivectomy with an electrotome tookplace in order to increase visibility. Cavity wasfinished with unsupported enamel prisms removaland resulted in a greater tooth loss, both inextent and in depth, than initially planned. Takinginto account the subgingival extent of the cavitymesially and the amount of tooth substanceloss, including cusps, it was decided to restorethe tooth with an onlay, by substituting the lostdentin and protecting the young vital pulp withan appropriate material. The patient wasconcerned about esthetics and longevity of therestoration and since she was not a bruxist, aceramic onlay restoration was regarded as thetreatment of choice. Biodentine™ was chosenas a dentin substitute and pulp protection underthe ceramic restoration. Restoration marginswere prepared with a high speed cone bur withrounded edge, the remaining distal cusps wereocclusally reduced in order to attain 2-mmspace for the ceramic and an additional mesio-distal groove was prepared to provide mechanicalstability to the restoration. Margins were roundedto avoid stress concentration on the restorationand on the tooth. Proximal walls were flared10-12o in total, 6o for each wall, using theappropriate cone-shaped diamond bur, paying

extra care to avoid undercuts (Fig. 5). Bioden-tine™ placement fully covering the preparedcavity, waiting at least 48 hours with Biodentine™,acting both as dentin substitute and as a tempo-rary restoration, before continuing the restorativeprocess at the next patient visit would be theconventional procedure. Based on previousexperimental studies (Yapp et al. 2012, Tolidiset al. 2013), it was decided to immediatelycontinue with the restoration process, afterBiodentine™ placement and setting. Biodentine™was applied, right after the cavity was formed.Biodentine™ was placed in a 2-mm thick layerat the deepest part of the cavity located mesially,covering the undercuts on the pulpal wall, wascondensed and was protected from moistureand allowed to set for 12 minutes according tothe manufacturer’s instructions. Subsequently,Biodentine™ surface was finished with a low-speed carbide bur. Dentinal walls of the onlaypreparation, which were covered with cement,were finished with a low-grit high-speed diamond

Fig. 3

Fig. 4 Fig. 5

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bur taking extra care (Fig. 6). In cases when theclinician decides to continue with the restorativeprocess directly after Biodentine™ setting, eitherwith a direct or with an indirect restoration, it issafer to prepare Biodentine™, if needed, withlow speed burs, to avoid complete removal ofthe cement from the cavity (Tolidis et al. 2013).Retraction cord was placed in the gingival sulcusat the mesial area, where the preparationextended subgingivally and impression wastaken with vinyl-poly-siloxane (Fig. 7). ShadeA2 was chosen for the ceramic restoration,matching the neighboring and opposite teeth ofthe young patient. The preparation was coveredwith a temporary light-cured material (Fig. 8),which is easily removed at the delivery appoint-ment with an explorer. During the second patientvisit, the ceramic onlay was tried in using specialcarrying sticks to prevent loss or damage to therestoration while handling (Fig. 9). Ceramic resto-ration was glazed. Before cementation, the innersurface was cleaned with 37% phosphoric acidapplied for 30 seconds (Fig. 10), followed by theapplication of a silane primer according to thecementation technique. Self-etching bondingagent was applied on the tooth structure, avoidingthe area covered by Biodentine™ and the resto-

ration was adhesively cemented with a dual-cure resinous cement, in order to increaseretention (Fig. 11). Excess resinous cement wasremoved with an explorer and contact pointswere checked with dental floss. The restorationwas light cured for 40 seconds from each sideand occlusion was checked with occlusionpaper and properly adjusted in maximum inter-cuspation and in mandibular moves. Visiblemargins were also finished with fine cone-shaped diamonds and silicon points. Patientwas instructed for daily oral hygiene and wasadvised to avoid biting on hard objects or foodat the area of restoration. No post-operativesensitivity or other symptoms appeared. Thepatient was followed-up in 6 months (Fig. 12,13, 14). Intraoral examination, radiographs andpulp vitality testing proved the success of thematerial choice and of the restoration process.Reactionary dentin formation is evident whencomparing the two radiographs (Fig. 3 andFig. 14). Last but not least the mesial restorationand the tooth margins were visually checked inhigh magnification photograph (Fig. 13) as wellas clinically with an explorer, confirming thatthe radiolucency shown in this area in the radio-graph seems to be of no importance.

Fig. 6 Fig. 7 Fig. 8

Fig. 9 Fig. 10

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Author: Christina Boutsiouki (christinaboutsiouki@gmail.com)Christina Boutsiouki graduated in 2011 and works as a general dentist. She isstudying in the post-graduate MSc course in the Department of OperativeDentistry, in Aristotle University of Thessaloniki, Greece. She is actively involvedin research since 2008, focusing on dental materials, operative dentistry andpediatric dentistry. She participates in dental conferences and has published 23 scientific articles.

References

01. Shala AJ, Simon J, Darnelll L. Biodentine as a base under CEREC restorations. Poster Session AADR2012, Tampa, Florida, USA.

02. Tolidis K, Boutsiouki C. Decay diagnosis camera: Is it a valid alternative? The International Journal ofMicrodentistry 2012;3(1): (ahead of publication).

03. Tolidis K, Boutsiouki C, Gerasimou P. Comparative evalutation of microleakage in direct restorations withCa3SiO4 bioactive material (Biodentine) under composite resin. Clin Oral Invest 2013;17(3):1083.

04. Walmsley AD, Walsh TF, Lumley PJ, Trevor Burke FJ, Shortall AC, Hayes-Hall R, Pretty IA. RestorativeDentistry, 2nd Edition, 2007, Churchill Livingstone, Elsevier.

05. Yapp R, Strassler H, Bracho-Trochonis C, Richard G, Powers J. Compressive deflection of compositelayered on Biodentine and two bases. Poster Session AADR 2012, Tampa, Florida, USA.

ConclusionBy utilizing this innovative approach, number ofpatient visits was reduced and the compromisedfirst maxillary molar was treated indirectly, provi-ding an esthetic restoration with long-termsurvival. Since it has been experimentally exhi-bited that direct application of the restorativematerial over Biodentine™ is effective and time-consuming, this case report represents theextension of this treatment idea in indirectceramic restorations. It should be howeveremphasized, that Biodentine™ needs extra carein handling when restored directly.

Fig. 11 Fig. 12 Fig. 13

Fig. 14

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Apicoectomy treated with an active biosilicate cement:Biodentine™Case report of a tooth Apicoectomy, endodontically treated with a retrograde fillingmaterial based on an Active Biosilicate cement, Biodentine™ Septodont.

Dr. César A. Gallardo GutiérrezDepartement of Endodontics, Universidad Cientifica del Sur, Lima, Peru

In clinical practice, we encounter complex proce-dures that often involve errors in the developmentof the endodontic treatment, both in the prepa-ration and the obturation, and which lead to thepersistence of the periapical lesion via the migra-tion of antigens in the region.The alternative we then have is retreatment,which is not indicated in cases of complexover-obturations or teeth that have been restoredwith posts, which complicates the procedureand could result in the loss of the tooth due tofracture or perforation.1

In the case we present below, we saw that theconditions for a successful retreatment wereunfavorable, we thus decided to perform peria-pical surgery.Periapical surgery consists in the exposure ofthe periapical zone and the removal of theaffected tissue followed by a retrograde resto-ration consisting in the apical preparation of acavity and its filling to ensure a hermetic sealand prevent percolation.2

Endodontics has made great progress in thelast decade in the development of new equip-ments, new instruments, advances in imagingand the development of new materials.1

In this case among the new materials we usedBiodentine™ developed by Septodont, as anew class of dental material that combines highmechanical properties and biocompatibility, witha calcium silicate (Ca3SiO5)-based formulation,which is a proven dentin replacement materialwhenever dentin has been damaged.3

Case Report A 48 years old female patient without pertinentmedical history came to the consultation withpain in tooth 12, she mentioned having beentreated a year ago.We observed in the clinical examination that thetooth has a ceramic metal crown. No increase inthe tissue volume was observed at the vestibularlevel (Fig 1), there is no sign of fistula, pain mani-festation on palpation and vertical percussion.

Introduction

19

The X-ray examination showed that the ceramicmetal crown was not sealed at the cervicallevel, through the radiotransparency of the crownfilling we noticed a fiber post, with absence offilling in the entire lumen of the canal preparedfor the post, we also observed an over-obturationof approximately 3 mm and extravasation ofthe sealing cement, located in a radiotransparentarea compatible with a chronic periapical process.(Fig 2)

Treatment PlanAfter the evaluation of the patient's conditionswe recommended:1- A surgical treatment, thus planning the exeresisof the extravasated material and the granu-lomatous tissue, apicoectomy with retrograderestoration,

2- Secondly, we recommended a new crownrestoration with adequate cervical seal.

TreatmentWe started the treatment with infiltration anes-thesia in the zone with 2% Lidocaine. The incisionwas made with a No. 15 scalpel blade, verticallyaway from the radiotransparent zone. We obtained

a flap of the total thick-ness, with two dischargeincisions resulting in arectangular flap. The zonewas detached with aperiosteal elevator withoutevidence of vestibularbone fenestration. (Fig 3)

Once the zone to betreated was exposed, weperformed an osteotomywith a No. 10 roundsurgical bur, once wereached the periapicalzone we carried out the

curettage, the over-obturated material and thesurrounding granulomatous process wasremoved, and washed abundantly with salinesolution to verify the removal of all the patholo-gical tissue. The apicoectomy was performedwith a fissure bur, creating as little bevel aspossible and following the direction of the apicalprocess. The apical chamber was prepared witha round bur following the direction of the rootcanal, at a 3 mm depth, it was thoroughlywashed with saline solution and the cavity wasdried with paper cones. (Fig 4)

Septodont’s Biodentine™, an active biosilicate-based retrograde obturation material was preparedaccording to the manufacturer's instructions,mixing 5 drops of the liquid (Aqueous calciumchloride and excipients solution) with the powder

Fig. 1 Fig. 2

Fig. 3 Fig. 4

20

(tricalcium silicate) for 30 seconds in the HenrySchein amalgamator Model: HS-1. (Fig 5, 6)

We then placed the appropriate amount of mate-rial in the prepared cavity and condensed it,after 12 minutes, completely isolated from fluids,according to the manufacturer's recommendation(Fig 7), the excess was removed. (Fig 8)

We placed Genox® Org Genius-Baumer bovineliophylized bone in the cavity to fill-in the bonedefect. (Fig 9)

We closed with 3-0 black silk suture, and treatedwith amoxicillin plus clavulanic acid 500 mg,every 8 hours for 7 days and ibuprofen 400 mgevery 8 hours for 4 days, as well as recommen-ding a 0.12% Chlorehexidine Gluconate mouthwash 3 times a day for 7 days. A control X-raywas taken. (Fig 10)

Discussion It was decided to perform the periapical surgerybecause it was impossible to eliminate the over-obturated material and the surrounding materialin any other way.1

Many materials have been used for retrogaderestoration, such as:-Cohesive gold, which has very good properties.However the very long working time involvedis a major disadvantage. -Gutta-percha, which does not have an accep-table sealing degree and is affected by thecompaction given as well as the humidity ofthe zone.

-Zinc phosphate and eugenolcements, which have a highlevel of solubility and irritationof the surrounding tissue. -Resin modified ionomers whichrelease monomers on polyme-rization provoking persistenttoxicity in the zone, and whoseionomeric part has a high solu-bility and therefore is notrecommended for this type oftreatment.4

Thus, the most commonly usedFig. 7 Fig. 8

Fig. 5

Fig. 6

21

material and with the greatest number of literaturereferences is silver amalgam, which is knownfor its mercury toxicity, it can tattoo the surroun-ding tissue with corrosion and the seal is pooras it depends on a retentive preparation.Another material which is increasingly used isMTA (Mineral Trioxide Aggregate), which is amixture of small hydrophilic particles of tricalciumsilicate, tricalcium aluminate, tricalcium oxideand silicon oxide, whose biocompatibility hasbeen widely demonstrated, as well as the abilityto induce the precipitation of calcium phosphateat the level of the periodontal ligament propitiousto the formation of surrounding bone repair5.On the other hand the seal it forms in the cavityis superior to other materials, improving withtime due to the absence of solubility, thuspreventing percolation.The main problem with MTA is that it is hard tohandle and to position in the retrogade cavityespecially when they are small or thin.Another disadvantage is the setting time whichcan last up to 4 hours after its application, withthe possibility of degradation during this period.6After this overview, we conclude that there isno ideal material for retrograde restoration, forthis reason Septodont developed Biodentine™as a new class of dental material that can

combine high mechanical properties and biocom-patibility, with a calcium silicate (Ca3SiO5)-basedformulation, which is a proven dentin replacementmaterial whenever dentin has been damaged.Following what we presented above concerningthe disadvantages of the materials previouslyused, Septodont tries to improve the clinicaltimes by adding to the active biosilicate settlingaccelerators and softeners, as well as a fasterand safer preparation with exact amounts for apredictable mixture in pre-dosed capsules tobe used in a mixing device, which makes itmore practicable and safe to use.7, 8

Calcium hydroxide forms as part of the chemicalhardening reaction of Biodentine™.9

The metal impurities observed in "Portlandcement" silicates are eliminated in the manufactureof Biodentine™ biosilicate. The hardening reactionis the hydration of the tricalcium silicate, whichproduces a calcium silicate and calcium hydroxidegel. Precipitates similar to hydroxyapatite areformed in contact with phosphate ions.10

An evaluation of the dentin-Biodentine interfaceshowed micro-structural changes in the dentin,and revealed an increase in the carbonate contentof the dentin interface, suggesting the intertubulardiffusion of mineral from the biosilicate hydrationproducts creating a hybridization zone.11

Fig. 9 Fig. 10

22

Author: Dr. César Antonio Gallardo Gutiérrez (cgallardo03@gmail.com)Endodontics and Cariology SpecialistMaster in Education and Research Post-graduate professor of the Endodontics Specialization Universidad Científicadel Sur, PeruDegree in Oral Rehabilitation, Universidad Científica del Sur, Peru

References

01. Cohen S., Hargreaves K., (2008) Vías de la Pulpa, Novena edición, editorial Elsevier España pp 737, 972

02. Sotelo y Soto Gustavo Alfonso, Trujillo Fandiño Juan José. Técnicas quirúrgicas en exodoncia y cirugíabucal, 2ª Ed. México, Textos universitarios Universidad Veracruzana, 2008.

03. Biodentine™ - Publications and Communications 2005-2010. Research & Development Septodont, Paris2010.

04. Meneses V, Técnica De Apicectomia en paciente de sexo femenino de 49 años de edad (Caso Clínico)Tesina Para Obtener El Título De: Cirujano Dentista Universidad Veracruzana Facultad Odontología PozaRica, Veracruz Junio 2012

05. Parirokh M, Torabinejad M (2010). Mineral trióxido agregado: Una revisión exhaustiva de la literatura-Parte I: química, física y propiedades antibacterianas. J Endod. 36:16-27.

06. Parirokh M, Torabinejad M (2010). Mineral trióxido agregado: Una amplia revisión de la literatura-Parte III:Aplicaciones clínicas, las desventajas y mecanismo de acción. J Endod. 36:400-413.

07. Wang X, Sun H, J Chang (2008). Caracterización de Ca3SiO5/CaCl2 cemento de composite paraaplicación dental. Dent Mater. 24:74-82.

08. Wongkornchaowalit N, Lertchirakarn V (2011). Ajuste de la hora y la fluidez del cemento Portland aceleradomezclado con superplastificante de policarboxilato. J Endod. en prensa :1-3.

09. Sobre I, Laurent P, O. Tecles Bioactividad de Biodentine:. Un sustituto dentina Ca3SiO5 basado Dent ResJ . 2010; 89: Resumen n. 165.

10. Colón P, F Bronnec, Grosgogeat B, Pradelle-Plasse Interacciones N. entre un cemento de silicato de calcio(Biodentine) y su entorno. Res J Dent . 2010; 89: Resumen n. 401.

11. Atmeh A. Dinámica interfaz bioactivo con los tejidos dentales. 45 ª Reunión de la División ContinentalEuropea de la IADR (CED-IADR) con la División escandinavos (NOF). 2011; no abstracta. 1.

ConclusionThe material has acceptable properties guaran-teeing the quality of the mixture by its pre-dosing,resulting in an easy to handle homogeneouscomposition.The biocompatibility advantages of active biosi-licate are known which gives us a high safetymargin of periapical biological response.

The disadvantage observed in the retrograderestoration was a low radiopacity of the materialin comparison with amalgam, which complicatesthe evaluation of the quality of the obturationseal.The first results observed in clinical practice arehighly promising.

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