Jeffrey W Horowitz

	With an ever-increasing number of implants being placed and restored in dentistry, the need for a reliable luting material cannot be denied.

	Implant restorations present the clinician with very different concerns than those encountered with tooth-borne restorations. The lack of traditional gingival architecture surrounding dental implants creates an increased risk for cement retention in the peri-implant sulcus which can lead to an inflammatory response and ultimately peri-implantitis.
	
	At the same time, retrievability is seen as a favorable trait in an implant luting material whereas most clinicians do not consider ease of crown removal for tooth-borne restorations.
	
	In the spring of 2019, Doxa Dental requested that Catapult Education evaluate an innovative product that addresses all of the above concerns-Ceramir® Bioceramic Implant Cement.

	Ceramir Bioceramic Implant Cement is a permanent, radiopaque bioceramic cement with excellent handling properties. Ceramir Implant Cement is 100 percent resin-free and self-setting.  It was purposefully engineered to provide good flowability and easy seating. Bioceramic technology is the key element behind the active ion exchange seen with Ceramir Implant Cement, and this also allows for a tight seal for ceramics and metals alike. By combining these qualities with an unprecedented ease of clean up, Doxa is confident in the clinical applicability of this product.

	Twenty of Catapult Education’s clinicians participated in the evaluation over the third and fourth quarters of 2019, after which they were surveyed to gain user perspective on the implant cement. Doxa Dental did not compensate the evaluators for their participation, nor was there any form of compensation to the clinicians.

	Most of the evaluators were already familiar with the chemistry and handling characteristics of Ceramir Cement with an impressive 60 percent of the evaluators already using this material for implant crown cementation. Of the current users, half reported that Ceramir was their exclusive implant crown luting agent of choice, while the other half reported having an alternative for varying indications such as short abutments or esthetic protocols.
	Interestingly, only one other single brand had multiple users amongst our evaluators, that being BISCO’s Theracem with three users. Of the eight evaluators that were not currently using Ceramir, seven different products were being utilized in differing material categories as follows;
	
	Resin Modified Glass Ionomer – 2; Implant Cements – 2; Theracal – 2; ZO-P – 1; ZO-E – 1

 Excess cement retention around implant-retained crowns is a primary concern for the restorative dentist. This was confirmed by asking our evaluators to rank required implant cement characteristics in order of importance. Overwhelmingly, nearly 90 percent of evaluators ranked ease of cement removal and clean-up as the most important attribute with marginal integrity as a distant second. The Catapult evaluators all rated this product among the best-in-class regarding ease of excess removal.
	
	

 When asked about the most important characteristics, it must be noted that biocompatibility was not one of the survey choices, though it is one of Ceramir’s most desirable characteristics. This was confirmed in our survey as 66 percent of respondents reported biocompatibility as Ceramir’s best attribute in a separate survey question.
	

(Figs. 2-3) Teflon Tape place to protect the abutment screw.

 When asked about their preferred implant cementation technique, 18 of the 20 evaluators stressed the need to minimize excess cement prior to final cementation over the abutment. To this point, almost half of the clinicians surveyed took the time to create an analog abutment, first seating the restoration over the analog to prevent excess cement on the intaglio surface. The remaining clinicians used either a brush or instrument to control excess.  The takeaway here is that while biocompatibility is incredibly beneficial to the peri-implant sulcus, removal of excess cement still remains a priority.

 In the categories of thixotropic properties, film thickness, working time and setting time, more than 80 percent of those surveyed rated Ceramir in the two most favorable columns with no responses at the opposite end of the spectrum. The only area that showed potential for improvement was regarding the convenience of use for Ceramir cement. While 75 percent of the evaluators felt that the material was either convenient or very slightly inconvenient, one-fourth saw some opportunity for improvement. Despite this, the value of this material to our clinicians was made very apparent with every single respondent reporting that Ceramir Bioactive Implant Cement is a product they would incorporate into their clinical formulary. This should not be taken lightly as getting 100 percent agreement from a group of dentists on any matter is quite impressive.
	
	

 Of the Catapult Evaluators, 20 percent responded that Ceramir ranked fair or less than fair regarding convenience, mainly regarding the dispensing system. The only other comment regarding dispensing suggested that the amount of force required to activate the capsule prior to trituration may be excessive.
	
	

 Every single evaluator from this panel of 20 plan on incorporating Ceramir into their practices. Only one felt that changes to the delivery system would be necessary to keep them from using a similar product if and when it became available.

	Rarely have the responses from this group of clinicians been so unanimously favorable for any product. The overwhelmingly positive response to Ceramir Bioactive Implant Cement from our evaluators has earned Doxa Dental and this innovative product the Catapult Vote of Confidence.
	
	While it must be noted that the high percentage of current users in our evaluator group may not be representative of the dental population at-large, it is absolutely a testament to the unique qualities of this product that every Catapult clinician who has tried Ceramir continues to use it.
	

(Figs. 7-8) Implant crown in place following an easy final cleanup. 

	This will undoubtedly translate to the at-large dental community. This can be further supported by the vast number of different products used by our evaluators who have the opportunity to communicate and collaborate. Only one other brand had multiple users showing that there is no agreed-upon standard for implant cementation.
	
	What is common knowledge, is that meticulous cement removal is a must around implants. This evaluation clearly supports that Ceramir is a leader in the ease of clean-up category.
	
	What is also known is that, despite our best efforts and intentions, small amounts of cement may be left by even the best of clinicians. To reduce the risks posed by this common occurrence, Ceramir boasts unprecedented biocompatibility.
	
	Knowing how common excess cement retention is, why would any clinician not use a product like Ceramir that makes it easier to clean up while being better tolerated by the surrounding tissues? Given the current material choices, Ceramir could become the gold standard for implant crown cementation, carving out a true niche in implantology that no other has yet claimed. 

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 that we develop with them. We have had many products that have either had 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 simply a product that needs refinement. Lastly, our clients are omnipresent in the industry, small to large, no favoritism, simply reviewing the latest products in our practices.

Articles

Ceramir Bioceramic Implant Cement earns unanimous praise from Catapult Evaluation panel with its biocompatibility, quick clean up, and easy handling.

Catapult Review: A Novel Implant Cement Universally Impresses

The Catapult Group evaluates a strong entry in the temporization category.

Kettenbach’s commitment to developing high-quality crown and bridge technique materials has been re-affirmed with the addition of their new provisional material, 

. With many major players in the temporary materials market, only a select few have emerged as having the combination of qualities that most practitioners require for confidence in provisionalization.

In their quest to confirm that Visalys Temp would meet or exceed practitioners’ expectations,  Kettenbach requested that the material be evaluated by  the Catapult Group, an organization of key opinion leaders (KOLs) and teaching practitioners spanning the entire U.S. and Canada, of which I am a member. There is no financial compensation to the dentists evaluating the product, and the end result is an honest, unbiased assessment, based on the clinical experiences of many.

Visalys Temp is a two-component, self-cured, multifunctional acrylic composite, suitable for the fabrication of temporary crowns, partial crowns, bridges, inlays, onlays and veneers. While there are many in this category, Visalys immediately stands out because of the absence of Bisphenol-A or Bisphenol -A precursors in the chemistry. Shades available include A1 through A3.5, B1 and Bleach shade.

There are several critical components that must be considered when evaluating a provisional material. These include ease of use, set and working time, fit, durability and polishability/esthetics. In my office, I handled the material as well as our expanded duty dental assistants to facilitate a dialogue on efficacy and applicability. Our first provisional was a single unit molar that was prepared for a full contour zirconia crown. 

As with most of our provisionals, an additional silicone matrix was made prior to tooth preparation. Dispensing was easy, and the material was clearly set by the one minute and twenty second set time as shown in the directions for use (DFU).

Upon removal from the mouth and matrix, the provisional was gently wiped with alcohol to remove the oxygen inhibited layer. At the end of this time, two minutes had passed and, per the DFU, the material would complete final curing from 2:20 min:sec until 4:00 min:sec.  By the time we had wiped the restoration with alcohol, it was notably hard, and we immediately began to trim the temporary.

Handpiece trimming and polishing was quite efficient (more so than with our current material), facilitated by the early hardness of the material. The temporary fit beautifully and contained no voids, so it was cemented to place with Temp-Bond clear. The results from our next 15 units (singles and multiples) yielded similar results. We did come to realize that setting times were indeed shorter than listed in the DFU. We removed all temps from the mouth within one minute and began trimming all after removal and alcohol wiping (about two minutes).

Trimming and polishing remained consistently simple and the esthetic zone temporaries were extremely appealing.  We experienced no adverse occurrences, such as fracture, or shade instability, and all agreed the material exceeded our current provisional material in virtually every category.

Having placed more than 250 provisional restorations with Visalys, the Catapult KOLs as a group  were also quite impressed, with nearly half of all evaluators rating the material as better than what they were currently using. When asked if they would switch their current product assuming a similar price, 78 percent of the group answered in the affirmative.

Finally, 90 percent of all evaluators  said they would have no reservations in recommending this product to their peers. These are all astounding numbers, considering the many material choices available and the ability for these KOLs to test many of them.

While all of the material’s qualities were evaluated, those most commonly mentioned by the practitioners referred to the excellent fit at the margins, fewer voids, faster set-time (time-saving), hardness, ease of trimming, polishability and handling. The consensus of the group was that being BPA-free was a distinct advantage for Visalys Temp, but it was merely the “icing on the cake” for a material that otherwise had superior characteristics in its category.

With any clinical evaluation there are always suggestions for improvement, though for this material they were few. The group felt that perhaps the working /set times should be shortened slightly in the DFU to prevent the possibility of early set and locking undercuts for a new user. There may also be an opportunity for Kettenbach to incorporate a slightly smaller mixing tip.

Short of this, Kettenbach has set themselves apart from the competition with Visalys Temp.  The physical characteristics of this provisionalization system make it ideal for short- and long-term use.

A 69-year-old male presented for emergency care with a fractured mandibular first pre-molar (No. 21)  (Fig. 1).

The tooth had been endodontically treated years prior, but never adequately restored. A core build-up and single unit e.max crown from Ivoclar Vivadent was planned with a Visalys Temp provisional restoration. Prior to preparation, composite was added to the fractured tooth to restore form for the addition silicone temporary matrix (Figs. 2-3).

Once preparation and impressioning were complete, a provisional crown was fabricated using Visalys Temp.  Prior to placing the new mixing tip on the Visalys cartridge, a small amount was extruded to ensure even flow of the two cartridge chambers (Fig. 4).

The mixing tip was placed in on position, and the viscosity of the material easily filled the unprepared matrix. The matrix was carried to the mouth and removed in less than one minute.  With a plastic instrument, the temporary crown was immediately removed from the matrix and wiped gently with an alcohol wipe (Fig. 5) to remove the oxygen inhibited layer. Shaping and polishing was immediately begun with a handpiece at approximately the two minute mark (Fig. 6).

By the five minute mark the restoration was seated with a provisional non-eugenol cement. Final occlusal adjustments and polishing were accomplished intraorally with a fine diamond and brownie point at low RPM (Fig. 7).

Visalys Temp was easy to work with, easy to shape and polish, and made for a durable temporary prosthesis. During the evaluation, shades were limited but the final esthetic results were still remarkable.

Visalys® Temp from Kettenbach LP is said to create demonstrably stronger temporaries that are esthetic, more fracture-resistant and manufactured without BPA. Visalys® Temp is a two-component BPA-free resin based on a multifunctional acrylic composite. It can be used to make temporary crowns, partial crowns, bridges, inlays, onlays and veneers including long-term provisionals.