Dr. Jack D. Griffin Jr. DMD MAGD AAACD ABAD

	So many cements, so little time. There are many excellent cements on the market today, but with many being so similar in appearance and performance, it’s hard to tell the difference. To look at it another way, there are many self-adhesive, dual-cure resin cements that you could hardly tell apart if there was no label. Some a little more viscous, some a little more translucent, some with a little slower set time - all very similar in most things that matter clinically.

The evaluators at Catapult Education clinically tested and reviewed a novel self-adhesive, calcium- and fluoride- releasing

 (BISCO). One hundred percent of evaluators said it was a cement worthy of use in their own practice. The most common features the evaluators liked the most were cleanup, handling and ease of use. Ninety-one percent of the evaluators said its consistency was just right, with 82 percent giving it a top score for ease in cleanup.

	An important consideration with TheraCem that distinguishes it from much of the cement market is its high calcium and fluoride release. As one evaluator put it, “Probably the best everyday cement in dentistry today. It’s easy to clean up, making it great for implant crowns. Its esthetics and simple delivery system make it perfect for routine indirect restorative … all this with high calcium release.”

	With zirconia and lithium disilicate dominating the indirect restorative market today, clinicians are looking for a versatile, esthetic, self-adhesive luting material that gives great long-term performance with either material. TheraCem comes in a “natural” shade, which is a somewhat opaque-looking luting material and, depending on the thickness and translucency of the restoration, could influence the shade. As someone who has used this cement in just under 500 units, this practitioner hasn’t seen this as a clinical issue.

	In this case with rampant decay, strength and esthetics with marginal integrity for a reduced chance of recurrent decay are all critical (

). After restoration of posterior teeth using silver diamine fluoride and other regenerative restorative materials, the maxillary anterior teeth were restored.

	Fig. 1                                                                                                  Fig. 2

	Eight monolithic anterior zirconia crowns were made with no layering porcelain (

). Note that this zirconia has noticeably more translucency than traditional posterior zirconia materials and can be seen through these restorations while on the model. The restorations where tried in and rinsed. Phosphates and proteins from blood, saliva and crevicular leakage lessen the bond to zirconia and a nonabrasive cleaner is preferred for maximum adhesion (

	Fig. 3                                                                                                 Fig. 4

	ZirClean™ (BISCO) was applied to each restoration, rinsed and air dried (

). The teeth were cleaned, isolated and filled with TheraCem (

	Fig. 5                                                                                              Fig. 6

	After placement, the chemical cure was allowed to happen for about 90 seconds, excess cement removed and then light cured (

. The easy cleanup makes this material unique in the self-adhesive, dual-cure resin cement world and the majority is removed in large pieces (

). Even with the very translucent zirconia, the influence of the cement is minimal, even at the margins.

Fig. 7                                                                                                      Fig. 8

	Notice also that the ease of cleanup results in thorough cement removal; this photo is minutes after placement (

). The high calcium and fluoride release provides a number of benefits that may ultimately result in longer lasting restorations given each particular case (

	Fig. 9                                                                                                Fig. 10

	BISCO has developed a great product in TheraCem, and for this reason, we are pleased to give it the Catapult Vote of Confidence. It truly is a cement that distinguishes itself in its category particularly in the zirconia and lithium disilicate world.

	1. Gleave CM, Chen L, Suh BI. Calcium & fluoride recharge of resin cements. Dent Mater. 2016 (32S):e26.

Articles

Why Catapult Group evaluators say this cement from BISCO is worthy of being used in their own practices.


Achieving consistency and easy cleanup with TheraCem

	With an aging population often comes incisal wear, abfractions and less-than-ideal esthetics. Patients often have sensitivity, challenged occlusions and compromised esthetics. The restorative dentist must address these concerns while using efficient procedures and effective materials that result in predictable long-term success.

In this case, the elderly gentleman had worn an upper denture for more than 50 years and was experiencing sensitivity to touch on the incisal edges of tooth Nos. 26 and 27. There was cold sensitivity on the lower incisor abfraction areas as well. There was also recurrent decay around the facial composite on the lower right bicuspid. He has been a chlorhexidine rinse user twice a day for more than 10 years, and staining was an ongoing issue (Fig. 1).

Related reading: Easy-to-use VOCO materials allow for natural-looking esthetics 

The wear of the opposing denture and acrylic teeth was significant enough to see the secondary dentin of the pulp.
	Flowable composites have become very popular restorative materials because of their versatility, but their lack of viscosity is often associated with high shrinkage and a less durable material. The GrandioSO Heavy Flow (VOCO America) lines of flowables are highly esthetic, provide great physical properties and are easy to work with. The GrandioSO Heavy Flow has 83 percent filler with wear and shrinkage comparable to many of the more viscous nano hybrid composites on the market. The regular GrandioSO Flow has more of a self-leveling ability. In this office, the assistant tries on different shades of the material, cures them, picks the correct color and then removes the samples from the teeth (Fig. 2).

Dentin and cementum surfaces that are exposed to the oral environment are not easily bonded. Contaminants such as chemicals, foods, fluoride and medications decrease the bondability of these surfaces unless they are prepared. Instead of using a bur and more aggressive dentin removal, the exposed dentin surfaces were air abraded using 50 micron aluminum oxide until frosty (Fig. 3).

	A MicroEtcher (Danville Engineering) was used to clean the dentin surface, remove the outer layer and provide micromechanical retention. The goal was not to remove healthy tooth structure as would be done if retention grooves were cut with a handpiece and bur but instead to change the surface area and prepare it for more successful adhesion.

The conservative nature of this treatment allows for healthy tooth structure to be maintained. By providing for the tooth surface preparation, our goal is 95 percent retention at five years of durable restorations. It must be stressed that no drilling, retention grooves or any other preparation was done at this time outside of micro-abrasion. It seems counterproductive to this practitioner to replace missing tooth structure by drilling away remaining tooth structure.

	A selective-etching technique was done by etching only the enamel with 37 percent phosphoric acid for 15 seconds and then rinsed well.

	The combination of acid etching of enamel and air abrasion of dentin results in frosty surfaces that provides an improved surface for bonding (Fig. 4). The surface area is greatly increased, and the contaminated outer surface is removed. Occlusal relief does not normally need to be done in these areas as the abrasion of dentin is faster than enamel, resulting in “dished out” areas that “naturally” provide ample clearance.


	
	Futurabond U (VOCO America) is a universal adhesive that gives high dentin and enamel adhesion with any bonding technique: total-etch, self-etch or selective-etch. The single-dose system removes issues with potential solvent evaporation by using a unique single-dose system (Fig. 5). 
	
	The bonding agent is massaged onto the tooth surface and lightly air dried (Fig. 6). After light-curing, the surface is shiny and ready for placement of restorative material (Fig. 7).

	GrandioSO Heavy Flow is applied, replacing the missing incisal enamel, covering the entire dentin surface and carried onto the enamel 1-2 mm. After curing, the same flowable material is used to replace the missing enamel, dentin and cementum on the facial surfaces. This flowable material has great adaptability yet stays where it is placed with excellent control with physical properties that allow it to be placed even on the occlusal surfaces of teeth.

The facial lesions on Nos. 26 and 27 and the failing composites are prepared at this point using a high speed handpiece and a 330 bur to remove the old restorative material (Fig. 8). Decay is carefully extirpated with a slow speed round bur and spoon.

	Air abrasion is then done on dentin/cementum surfaces as described above with the goal again to preserve healthy tooth structure. After selective-etching and universal bonding agent application, the lesions are restored with two layers of GrandioSO Heavy Flow and cured.

	The restorations are shaped with a finishing bur on a high speed with light pressure and water. The occlusion is then checked (Fig. 9). The premature contacts, as seen on tooth No. 26, are adjusted with a finishing diamond (Fig. 10).

	Care is taken when shaping and finishing to reduce stresses on the restorative material by using sharp finishing instruments, light pressure and water to decrease heat buildup and iatrogenic marginal degradation (Fig. 11).

	The restorations are then polished with polishing cups and Dimanto (VOCO America), leaving a highly smooth surface. All restorations are left moist to dissipate heat then given a final cure of 20 seconds on each restored surface.

	This conservative treatment is excellent service to the patient. Sensitivity is reduced, esthetics are improved and enamel is replaced with dentin and cementum sealing. This combination of technique and restorative materials provides durable, esthetic, patient-pleasing restorations with minimal invasion into healthy tooth structure (Fig. 12).  

A conservative treatment with Futurabond U and GrandioSO Heavy Flow delivers esthetics, reduced sensitivity.

With an aging population often comes incisal wear, abfractions and less-than-ideal esthetics. Patients often have sensitivity, challenged occlusions and compromised esthetics. The restorative dentist must address these concerns while using efficient procedures and effective materials that result in predictable long-term success.

How to manage exposed dentin: a great patient service

	The Catapult reviewers give high grades to these economical handpieces.

Catapult is an organization that consists of more than 50 clinicians spread throughout Canada and the United States. As a company, manufacturers pay a fee for their product to be evaluated, and what we deliver are truthful, independent answers from surveys we develop with them. We have had many products that have either needed to be altered before hitting the market or simply never arrived because of our openly honest evaluations. In this way, Catapult assists the manufacturer to avoid potentially releasing a faulty product or one that needs refinement. Lastly, our clients are omnipresent in the industry, small to large, and show no favoritism, simply reviewing the latest products in our practices.

The AG Neovo Dental Evolve handpieces are one of the great values in dentistry. They are smooth cutting, quiet and have a very comfortable, ergonomic feel. Their Enduro™ Chuck has given excellent clinical performance with the durability needed to be a workhorse in a busy practice. The AG Neovo Dental handpieces, despite their terrific clinical performance, cost half of some of the competitors while exceeding them in performance.


	The Evolve series is a very lightweight line of handpieces with a nice “Apple-like” metallic finish with an etched area for good finger grip. Both the regular and mini head size have very good power and torque with sizes that easily access small places-even upper second molars. The concentric turbines are powerful without wobble or vibration and cut with ease.

	They have a balanced feel, making the AG Neovo Dental brand likely to reduce hand fatigue with a long day of drilling. The sound is mellow with less shrill than many other handpieces we have tested while the autochuck is very reliable with good bur holding. The light is bright and located in a good position for even illumination, and the four water sprays on the regular head are exceptional. The mini head has only one water port because of its small size but is more than adequate.

	Even though these handpieces have been very dependable, there is a peace of mind knowing that everything from the LED light to the turbine has a two-year warranty. Even the turbine is warrantied for 24 months for bur retention. We have had excellent durability in a very busy office using a couple of different autoclaves and a cleaner/lubricant station. The surface finish and design make the cleaning very simple with very little surface debris build-up.	The Evolve air-driven high speeds fit several couplers on the market, including 

, making transition to them simple and stress-free. Maintenance is straightforward and consists of cleaning, lubrication and autoclave sterilization.

, a consortium of key opinion leaders and educators, rated the AG Neovo Dental handpieces very highly. Nineteen of 22 evaluators rated them excellent with 21 of 22 recommending them to a colleague. The most important factors for these evaluators were design, ergonomics, weight, feel, cutting efficiency and durability. The high Catapult ratings for the features mentioned above, coupled with the warranty, price and quietness, make this brand of handpieces easy to recommend to a friend while getting the Catapult vote of confidence.


	This series of air-driven handpieces includes high and low speed handpieces, as well as compatible air motors and couplings. The ergonomically designed, lightweight, high speed handpieces employ an Enduro™ Chuck design and ceramic ball bearings that are designed to achieve greater cutting efficiency and minimal noise. The tip of the Enduro™ Chuck is constructed from tungsten carbide, which protects it from wear and ensures longer life. Also, the precise alignment between the turbine and bur results in better cutting efficiency, lower noise and enhanced patient comfort.

We are all looking for high speed handpieces that have great clinical performance and longevity.
The AG Neovo Dental Evolve handpieces are one of the great values in dentistry

A review of AG Neovo Dental Evolve Series handpieces

The Catapult Group and Key Opinion Leaders review this pulp capping material and liner. 

 is in a new class of materials called Resin Modified Calcium Silicates (RMCS) that has been reported to stimulate apatite formation and the formation of secondary dentin1. Technically it is an alkaline calcium silicate based on the chemistry of MTA (Mineral Trioxide Aggregate), which has a lengthy history of a favorable hard tissue promoting response.

TheraCal LC was designed to aid in the regenerative process by stimulating apatite formation and provides the early high alkalinity, pH 10-11, required for pulpal healing and reverts back to a neutral pH after several weeks. It is self-sealing, which reduces the chance of being accidentally rinsed off or blown off during air-drying. Its high calcium release is critical for the stimulation of apatite formation and secondary dentin bridge formation while providing a mechanical seal of the pulp (exposed or non-exposed) without adhesive2.

Bisco took more than 10 years to develop and test this product, so it comes with a thorough background check. 

 in that there is no waiting time for chemical curing to occur because of its light cure properties. The definitive restoration can be placed immediately.

TheraCal LC is intended as a liner with a depth of cure of about 1 mm. As a liner, it insulates and protects the dental pulpal complex. It is placed from a syringe with a small tip very much like a flowable composite. It is easily placed in deep, difficult to reach areas of the prep. It also is highly radiopaque for easy radiograph visualization.

In this office, there are two main indications for TheraCal LC in restorative dentistry.

First as direct pulp capping material where it seals the wound of an exposed vital pulp and assists in providing a reparative dentinogenic response for maintaining dental pulp vitality 

. The second indication is as a liner over the deepest part of the prep nearest the pulp. The material acts as a barrier to protect the pulp, which may induce the formation of a new dentin bridge between the pulp and restorative material 

TheraCal LC certainly could work as a liner to completely cover the dentin, which would provide the maximum in pulpal and sensitivity protection. There are two reasons we may not want to cover the entire dentin with this material. First, the bond of this lining material is not as strong as that achieved from a separate dentin bonding agent, total-etch or non-etch. Secondly, this material is opaque and may show through a more translucent composite. It is important to stress that the light cure feature is convenient, but TheraCal LC is a LINER and meant to be no more than 1 mm in depth for proper curing.

The question in everyday practice becomes when do we do indirect or direct pulp capping and what can we expect as a clinical result. In our office we have found that by using TheraCal LC in very deep preparations we have seen a substantial reduction in sensitivity over merely bonding and placing composite in a deep preparation because of its insulating capacity.

After 25 direct pulp exposures in our office, we have had about 90% success (little sensitivity, no PA lesions, no need for endo after 1 year) as long as bleeding is easily controlled, the pre-op tooth was asymptomatic, and no PA lesion was present.

Key Opinion Leaders in Catapult evaluated TheraCal LC very favorably, with 70% saying they would use it to replace the material they currently use for lining and pulp capping.

The group has used a wide variety of materials, including calcium hydroxide, MTA, dentin bonding agents alone, bulk fill composites, and resin modified glass ionomers. The material’s handling and delivery system was very well received with high marks for syringe dispensing and light cure ability. The visible light curing feature is outstanding and makes the material an optimal choice over calcium hydroxide, with 100% of reviewers saying this was a nice feature.

The reviewers did have one minor request - to have a slightly less viscous material that would be easier to place in smaller deep cavities. The scientific rationale for using an alkaline material was well accepted in the group. This, combined with the ease of use, makes it a preferred material for direct pulp capping.

A patient with no real toothbrush experience came in as an emergency with a broken incisor (Fig. 1). 

The patient had no sensitivity but came in only for the esthetic deficiency and the radiograph showed no PA lesion (Fig. 2). A 330 bur was used to prepare the tooth followed by a spoon excavator to remove decay. There was a small pulp exposure and bleeding was minimal and controlled with bleach on a cotton pellet (Fig. 3).

The removal of decay is verified with a caries indicator to decrease the number of bacteria in the preparation, which may be important to “healing” a healthy exposed pulp.

A thin layer of TheraCal LC was placed directly on the pulp and onto moist dentin about 2 mm beyond the exposure and away from the enamel (Fig. 4). Light curing was completed for 20 seconds each from the facial and lingual (Fig. 5). Again, it is important to note that this is a liner and is placed directly over the pulp and onto healthy dentin about 2 mm. This will allow adequate dentin on which to bond for an overall increase in restoration strength.

All enamel surfaces were beveled with a long, irregular prep and then a celluloid strip placed (Fig. 6).

A total-etch technique was done for 15 seconds using an etch with Benzalkonium chloride (Etch-37 with BAC, Bisco), rinsed well, and followed by a universal bonding agent (All-Bond Universal, Bisco). After several coats we air thinned until there was no bonding agent movement. A high fluoride releasing giomer composite was placed (Beautifil, Shofu), cured and finished (Fig. 7).

This is a common case in a busy office. We often see unexpected exposures or near-pulp involvement, and our goal as clinicians is to provide a service that is conservative, dependable and of great value to our patients.

In pulp capping cases like the one shown here, we expect a well healed pulp with little sensitivity with little chance for future endodontic need, as long as all decay was removed and excellent sealing and bonding is maintained.


	1. M.G. Gandolfi, F. Siboni, P. Taddei, E. Modena, C. Prati. Apatite forming ability of TheraCal pulp capping material. J Dent Res 90(Special issue A);2521:2011.
	2. M.G. Gandolfi, F. Siboni, P. Taddei, E. Modena, C. Prati. Chemical-Physical Properties of TheraCal Pulp-Capping Material. IADR abstract #2521, March 18,2011.
	3. Goldberg M, Smith AJ. Cells and estracellular matrices of dentin and pulp: a biological basis for repair and tissue engineering. Crit Rev Oral Biol Med. 2004 Jan 1;15(1):13-27.	4. Modena KC, Casas-Apayco LC, Atta MT, Costa CA, Hebling J, Sipert CR, Navarro MF, Santos CF. Cytotoxicity and biocompatibility of direct and indirect pulp capping materials. J Appl Oral Sci. 2009 Nov-Dec;17(6):544-54
	5. Desai S, Chandler N. Calcium hydroxidebased root canal sealers: a review. J of Endodontics. 2009, 39, 415–22.			 			

Bisco's TheraCal LC will 'replace current lining, pulp capping material'

			The Catapult Group and Key Opinion Leaders review this pulp capping material and liner.			Written by: by Dr. Jack D. Griffin Jr., DMD, MAGD, AAACD, ABAD			Bisco's TheraCal LC			Date published: 03/15/2013			70% / 5 stars