Game Changers

BY LOUGRAHAM

DDSFor more about

Lou, see his full bio on page 4

As a reviewer for the Catapult Group, each year

we evaluate 15 or more new products that are

coming into our dental market and like you,

I ask myself the essential questions:

Does this product ultimately deliver a better

result than one I am currently using?

Does this product add time to the procedure,

or is it more efficient in its use?

In the same regard, I ask myself, is it easy to use

or so challenging that I won’t want to use it?

Is the product more expensive and if so,

is it worth it?

Is this product beneficial to my patient

and in what manner?

BUSINESS & PRACTICE DEVELOPMENT

SPRING 2014 | TheProDentist.com

temporary cement on vital teeth which we all know can be very uncomfortable. The cement is antimicrobial and provides excellent retention. If you are currently using a temporary cement that does the above, don’t change, but if not, enjoy the change.

Thus the 15 minute appointment starts with relative easy removal of the temporary crown, no anesthetic, minor adjustments and then we are ready for the final cementation. The next step is to rinse the crown internally out with water and then simply place Ivoclean from Ivoclar into the crown for 20 seconds and rinse away followed by air drying (Doxa has shown that Ivoclean is not required prior to usage with Ceramir cement). This cleanses the internal surface and prepares the internal surface to be cemented. This works for all different types of crowns, dilithium silicates, zirconia and metal. This again is a technique that satisfies my critieria of change: easy, cost effective, long term better cement internal surface adaptation to the crown.

The final step without question is to cement a crown and that cement should have the following properties:

• Long term permanent seal• Internally can create new apatite

crystals as it integrates with dentin• Inhibit caries• Inhibit plaque• No micro-leakage• Moisture tolerant• No shrinkage• Biocompatible both internally and

externally• Low solubility• Strong physical properties such as

flexural and compressive strengths• Thin film thickness• Universal usage for all ceramic

crowns, metal crowns and implants

• Good working and setting times both for single and multiple units

• Superior retention• Comfortable with minimum

sensitivity• Easy Cleanup• Long term studies

As you look up at the above, the vast majority of cements cannot fulfill the above criteria and Ceramir cement by Doxa performs with each of the above requirements. With over 300 crowns cemented in my own practice and well over 2000 in the Catapult Group in just the past 2 plus years, the cement stands out with all of the above characteristics.

The process involves the dissolution of powder after the activation of the capsule and trituration causing a re-precipitation where particles in nanometer sizes are built and bond upon each other at a basic pH. As the material dissolves it wets the tooth (hydrophilic, keep the preparation moist if possible) and then as the nano-crystals begin to form they precipitate on the tooth surface and upon other crystals. Within minutes the hardening mechanism begins creating a dual functional result: sealing the interface and creating the conditions necessary at the interface of building hydroxyapatite. In essence, it’s

Clinical efficiency can be no better explained than what I term the crown delivery appointment. Doctors range from 15-45 minutes for the delivery of their laboratory crowns and the question, why such a variation? A quality lab, should deliver a restoration (based on a good preparation and impression) to the office requiring very few adjustments. Such adjustments are made if required at the contact areas and occlusally. The usage of articulating paper both interproximally and occlusally allows the practitioner to adjust specific areas and then once adjusted and polished, the crown is ready for delivery. Sounds simple but all too often the process becomes far more complicated and time consuming because of the cements and various other adjunctive treatments we utilize both for temporization and final cementation.

LET’S WALK THROUGH THE APPOINTMENT AND YOU

WILL SEE WHY I HAVE TWO VERY DIFFERENT CEMENTS.

For your everyday temporaries, my recommendation for usage is Cling² by Clinicians Choice. I was introduced to this cement two years ago when the Catapult Group reviewed the product and these are the reasons I have incorporated this into my clinical techniques. The cement comes out with the temporary, and does not stick to natural tooth. The only time it sticks to the tooth is too a bonded buildup which is easily is removed from the build-up. The beauty of this, the patient does not have to be numb rarely for removal of

Given those questions, few products that I see every year are what I term “game changers”. Doxa’s Ceramir cement

is a game changer and answers all of the above questions with a definite YES. Cementation ultimately is one of the

most critical procedures we perform almost every day in our practices and truth be told, we all require a product

that delivers the ideal seal from acid attacks, bacteria, moisture, heat, and the associated challenges that occur

every day in the oral cavity because a crown’s margin is truly only as good as the cement. Yes, accuracy matters,

but again, you can have the best margins, but without the ideal cement, those margins eventually break down. This

article will touch both on the uniqueness of the chemistry and the clinical procedures involved with this cement.

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adhesion to the tooth takes the same form as its infrastructure. Another important feature of this cement is that when the powder is dissolved, hydroxide ions are released, created a basic pH. This higher pH is critical on many fronts because it not only creates an environment conducive to growing hydroxyapatite but also stabilizes the hydroxyapatite (hydroxyapatite breaks down with acid). Long term, this means it’s caries resistant, i.e. to acid attacks.

Doxa has now published 2 year data and has 3 year data confirming: no loss of retention, no secondary caries, no marginal discolorations, and no subjective sensitivity. There are no longer term studies are available from Sweden.

With all this said, let’s bring this down to earth and truly explain how this may be the game changer in the cement category. Once the internal surfaces of: all zirconia crowns, zirconia to porcelain, gold, porcelain fused to metal and lithium disilicate (prepared via the guidelines of eMax) crowns are all cleaned in the proper way (described earlier), this cement can be used for all of the above without any silanes or primers. This avoids unnecessary materials, potential mistakes and in fact makes the process far more universal and simplified.

Ceramir makes an ideal universal posterior cement with exceptions: These include: ceramic inlays/ onlays, and underprepared e Max crowns which required adhesive cements to support the thin dilithium silicate crown. This author has also used this material for anterior restorations fabricated out of: zirconia to porcelain, e Max and porcelain to metal restorations. The exceptions in the anterior category would be veneers, Empress ,feldspathic crowns and any ceramic crown that is thin (the white will shine through and these minimal preparation crowns require adhesive resin cements for further support internally.

The beauty of this cement, after

placing it into the mouth and waiting 3 minutes, cleanup is as easy as any resin-ionmer cement. Seating multiple crowns (all at once) is equally easy and the capsules come in single dose and multiple dose (up to 3 crowns). Another quality thus far not discussed is the thickness. It’s very thin, 15 microns and makes for a wonderful implant cement because it is tissue biocompatible which becomes very important in that peri-implantitis is often the result of excess cement that is NOT biocompatible.

THE CEMENTATION PROCESS:

The cement is hydrophilic so routinely once I am ready to cement, I soak the preparation for 60 seconds in 2% chlorhexidine for final cleansing (Cavity Conditioner by Bisco) and then rinse or blot with wet gauze and leave the preparation mildly moist. This is all being done while my assistant follows the 4 step protocol for the cement.

STEP 1Place the capsule in an activator

that comes with the kit, and press down for 3 seconds

STEP 2Triturate for 5 seconds a single dose or 8 seconds a multi dose

STEP 3Remove the capsule from the

triturator, rotate the nozzle of the capsule and then place it is

dispensing instrument that also comes with the kit

STEP 4Dispense the material

into the crown.

A working time of 2 minutes allows you to seat multiple crowns if required, and clean up begins no later than 3 minutes. Removal of the cement is

similar to that of a resin-ionomer cement, with no light curing. So at the 3 minute mark you remove the excess cement, floss down and wait the full 5 minutes for final flossing and say bye-bye. Helpful hints include: verify cement extrusion 360 degrees from the crown as it is seated, if not, simply remove the crown, add more material and reinsert, remove excess cement on the soft tissue not related to the margins, this can be in the vicinity and prior to setting, the cement is very easy to remove.

Sensitivity is virtually non-existent and again another benefit to the patient, comfort and no anesthesia required. Another key issue, that is not routinely discussed relates to what happens when these all ceramic crowns in the future require removal? As many of you have experienced, removed resin cemented ceramic crowns, especially those in the posterior require far more time because the cement often masks natural tooth structure and all too often we can’t simply remove the crown without sacrificing tooth structure. These crowns often cannot be just sectioned off in two pieces like PFM’s and this equally adds to time and stress for the practitioner. With Ceramir, I have had to remove 2 crowns cemented with this material due to drifting and hence open contacts (don’t you love those). When sectioning through the crowns, one can see the white opaque cement which is such a positive! Yes, the cement has excellent retention, and removal was more than a simple slice, but both were far simpler than resin cemented restorations.

In summary, Ceramir cement with its biomimetic properties sets itself apart from other current cements on the market. This simplified 4 step activation- insertion procedure allows everyday cementation to be delivered in a symptom free manner with usage for the vast majority of anterior and posterior crown restorations in our practice.

To review clinical cases, please visit Doxa’s Learning Center at www.catapultuniversity.com