Elevation extractions, when completed atraumatically and efficiently, are among the most satisfying to me. It’s the feeling of going into a potentially challenging situation with a plan and then only needing to utilize a portion of the plan to accomplish the entire goal that gives me joy. Sometimes it happens because the anatomy was favorable but more often, it’s experience and an advanced armamentarium that resolves the issue at hand.

In this article, I plan to discuss structural and procedural aspects of the Xpanders elevator, my standard extraction process and 2 case studies explaining why these atraumatic elevators from ArtCraft Dental are a crucial part of my surgical kit.

The Xpanders at first glance look similar to the 301 surgical elevator you first grabbed in dental school. A bulbous handle extends into a round shank that eventually develops a concave and convex semicircle shape as you approach the tip. Then the details emerge about why they are so special. Most obviously, the Xpanders have a 2-pronged tip instead of a standard shovel shape.

Curved to engage the surface of the root, they are also impregnated and roughened with a proprietary ceramic material that is blown onto the tips during an intense heat treatment process. These tips concentrate force from the large handle to allow quick and focused compression of bone and penetration of the periodontal ligament (PDL) space during a vertical elevation approach.

However, since they are made of relatively thick steel, they will only penetrate about 0.5 mm and are therefore relatively noninvasive. Then, even with minimal rotation forces applied, this instrument will quickly create instability of a root that was otherwise firmly held in its socket.

The handles are made from surgical-grade French stainless steel. They are wide and easy to grip but hollow for lighter weight and correspondingly less wrist fatigue. The interior is confirmed to be airtight during the manufacturing process so they are still safe for standard sterilization protocols. The tips are thick and strong enough to be used in a horizontal elevation motion or direction but that could possibly affect the lifetime of the instrument. In extreme situations, I find that the spread of the tips creates a great 2-point contact where one establishes a purchase point on the ridge and the other provides the upward and outward force needed for expulsion of the remaining root.

The class I lever action that’s typical for an elevator lifting tooth against bone is even more effective with the shape of the Xpanders forceps because of the increased distance between the active points. A typical elevator functions by putting force on the tooth with one edge and then resting with the center of its convex back against the bone. Compared with an equally wide 301, Xpanders achieve almost double the distance of a lever action due to the double-pronged design. Since an average PDL width is under 0.5 mm, there is often very little space to penetrate. Assuming that there is some ferrule remaining at least 2 mm above bone, I choose the Xpanders as my first option for a specialized lifting instrument since it can generate high moment forces between its arms and it grips well with the ceramic coating. If the tooth is equal in height to the bone or below, I prefer using a PDL knife, luxator, or spade elevator to open the space just a little farther using apically directed wedge action and more delicately sever the ligaments before advancing to the Xpanders.

While they are strong enough to withstand rolling wheel-type elevation motions, I don’t rely on the Xpanders for interproximal pressure with molars unless I have sectioned the roots out of concern for breakage of the arms. That being said, I also haven’t witnessed breakage or signs of fatigue in the year that I have been using them. I do find that they are more helpful at removing conical-shaped roots than tripod roots, but that isn’t an issue if you plan to section and separate the roots anyway.

My usual protocol for extraction is as follows:

3. Radicular stability test with 301 or standard elevator

5. Choice of spade or PDL knife vs Xpanders for luxation

6. Use Xpanders with vertical apically directed force with ¼ reciprocal twisting motion and complete this motion on each of 4 interproximal corners if possible with properly angled instruments.

7. If the root is lifted and mobile enough, secure with a 151 or 150 and remove or if the PDL space is wide enough, reintroduce a standard elevator.

9. Curette socket with serrated spoon curette.

10. Place collagen clotting aid or graft if appropriate and close with membrane and sutures.

Oftentimes, I am able to extract teeth with only periosteal and Xpanders elevation, but they are also useful in more difficult cases. To illustrate the effectiveness of the Xpanders and expound on how I use them, below are 2 recent clinical examples.

The first case involves a 34-year-old man who was currently taking no medications, was a nonsmoker, and had a midrange caries risk due to past issues with substance abuse (

). He needed extraction of #12 following a chronic apical abscess that led to a large swelling extending to the orbit.

After reducing the swelling with antibiotics and steroids, I saw the patient for the extraction of the tooth and grafting of the site in preparation for a future implant. I anesthetized the site with 3 carpules of Septocaine (Septodont USA) circumferentially and then lifted the surrounding gingiva and periosteum (

). The goal is always to maintain all walls of the socket, but I am especially careful with bony structures when I am planning to graft. After exposing the tooth-bone interface, I inserted a 301 into the embrasure on the non-
decayed mesial of the tooth to create some minor horizontal force and mobility (

Then I placed the tips of the straight Xpanders into the mesiobuccal corner of the tooth at the PDL line and apically pressed about 30° off the vertical axis of the tooth while doing quarter-turn twists back and forth in a reciprocating fashion. After increasing the mobility and reaching a vertical stopping point, I moved to the mesiolingual corner of the tooth and completed the same motion. The distobuccal corner had significant decay so I gained greater access to the PDL with a spade elevator before engaging with the Xpanders. The distolingual corner wasn’t easily accessible, and I chose not to open more of the Xpanders kit since enough mobility had been gained. I attempted to deliver the tooth with a set of 150 forceps but the coronal portion fractured (

). I reengaged the straight Xpanders and drove them apically until the root popped up enough to grip with the forceps. I followed through with curettage until the site was devoid of granulation tissue and adequate bleeding had been established with a serrated spoon (

). All walls were maintained so I filled the site with particulate allograft to the height of the ridge and closed with a membrane and Vicryl sutures. 

The second case involves a 39-year-old man with no significant medical history or medications (

). Tooth #15 had a history of root canal treatment and crown (

). Hewas seen at a previous appointment by my associate with the crown off and significant recurrent decay was diagnosed on the mesial aspect from a food pack.

The failure of the crown rendered the tooth nonrestorable but it was recemented and the patient was scheduled with me for the extraction. There was no swelling or purulence, so effective anesthesia required only 2 carpules of infiltration with Septocaine. Since the crown attachment was likely compromised due to the decay, I proceeded to periosteal elevation (

I was able to use the “Posterior In” Xpanders to get a good purchase point on the mesiobuccal corner of the mesiobuccal root and worked that angle until the crown popped off (

). Since there was extensive decay and it was root canal treated, I had expected to section the roots at some point during the procedure and prefer to do this prior to elevation. However, in this situation, I elevated first since I knew the cemented crown would not hold up to pressure. I use a reverse-vent, air-driven surgical handpiece but still like to maintain a periosteal seal as much as possible to prevent pneumonias from debris, air, or water into the fascial planes.

I completed a y-shaped sectioning of the roots with my handpiece and was then able to engage the distobuccal root on its mesiobuccal corner. This quickly created instability, and I removed the distal root with the Xpanders only. The decay on the mesial root caused repeated fracturing upon elevation force and necessitated further osseous reduction. Final removal of the apical portion required root picks. The palatal root was easier to access with the “Posterior Out” Xpanders on the distolingual aspect and the “Posterior In” Xpanders on the mesiolingual and moved buccally enough to allow for removal with a set of 150 forceps. The patient elected not to graft at this location, so hemostasis was confirmed and the patient released. 

The first case was atraumatic to surrounding bone, swiftly completed in about 15 minutes, and the site is now moving on its way to ridge regeneration for future restoration. The second case was not so quick and easy but we achieved success through implementation of a good plan with great instruments. I hope this article has provided you with ample reason to try something a little different and to elevate your surgical setup with an Xpanders kit (

). The drawing indicates the proper positioning for use (

Articles

One clinician explains why the Xpanders elevator from ArtCraft Dental is a valuable asset in his practice.

How to Perform Elevation Extractions Atraumatically and Efficiently

Nausea, indigestion, upset stomach, diarrhea.” If you are even close to the same age as I am (I was born in 1978), you probably will have no difficulty placing these lyrics. They are from a hugely popular Pepto Bismol commercial jingle. The symptoms listed above, while incredibly displeasing, are a part of life, and thankfully the pharmaceutical industry has provided products that aim to mitigate 

Whenever I am faced with a bulk-fill situation, a much less catchy jingle plays in my head:

“Depth of curing, polymerization shrinkage, marginal leakage, sensitivity.”

Every dentist is quite familiar with these terms. We hate them, and like the occasional gastric issues we must face, they have been relegated to a displeasing part of life. Many products have been introduced that aim to mitigate these issues, but most have 1 or 2 glaring characteristics that make them less than ideal for the incredibly common need for placement of huge restorations. Let’s talk about each one of these products.

Traditional Light-Cured Bulk-Fill Flowable Composite

Flowable light-cured material that has higher levels of filler particles is incredibly convenient. The flowable nature allows the material to seep into deeper crevices, and the high concentration of filler product at least attempts to reduce the amount of polymerization shrinkage of the resin monomers when cured.

There are 2 big problems with this option. First, the more filler particles, the less chance for the curing light to penetrate deep into the prep (

). Second, even if the light cure penetrates to the entire bulk fill, this will result in simultaneous monomer polymerization, making shrinkage, marginal leakage, and sensitivity highly probable.

Packable composite has a much higher concentration of filler particles, giving it a higher modulus of elasticity and resistance to wear. Because of the filler particle density, however, curing-light penetration is limited to 2 to 3 mm, requiring the clinician to apply, pack, and cure in small increments. This is not only inconvenient and time-consuming, but every incremental fill opens the door to the possibility of voids (

). Large fillings by their very nature have small crevices and potential undercuts, so it is impossible for the clinician to have complete confidence that all of those were filled in with the already-firm composite.

Although resin-modified glass ionomers (RMGIs) generally require a curing light, there is a self-cure component that makes the RMGI mechanism different from traditional composites. If a dentist chooses to wait for the product to chemically cure, it should, theoretically, eliminate the issues of curing-light penetration, shrinkage, and leakage. And RMGIs do successfully eliminate the first 2 issues; however, leakage and voids are still highly probable given the overall viscosity of this material.

The material is somewhere between flowable and packable, so if a dentist chooses not to light cure, they would extrude the material, wait a little while, and then attempt to pack it. Moreover, the limited amount of material in each RMGI capsule often runs out and requires another mix for large restorations. This is time-consuming and inconvenient, but more importantly, it introduces the potential for voids and leakage as we attempt to pack the newly mixed material onto the already-packed material (

). Because most dentists choose to light cure this material to save time, the same issues of microgaps and shrinkage can still occur.

Lastly, RMGIs simply do not have the same surface shine and polishability of traditional composites. The surface poses aesthetic problems and feels rough to the tongue. This is not an issue for crown buildups but certainly can be frustrating for direct resin restorations.

Dentistry is, and probably always will be, difficult at times. No matter how much we try, patients will have limited opening, chubby cheeks, poor oral hygiene, and “gagginess.”

Thankfully, innovators constantly introduce strategies and products that make our lives just a little less painful. In this article I show how SDI’s Stela solution makes lives easier for clinicians.

In part 2 of this feature, we’ll take a close look at how this a self-cure bulk-fill flowable performs. This unique product self-cures at the point of contact with its proprietary primer/adhesive.

Stay tuned to learn more about the benefits of SDI’s Stela solution.

[ Sponsored ] In this article the author shows how SDI’s Stela solution makes lives easier for clinicians.

SDI’s Stela Self-Cure Bulk Fill Flowable Self Cure Restorative Delivers Stress-Free Bulk-Fill Restorations

Over the course of the last 7-plus years, I’ve written in great detail about the need for dental offices to protect and secure their most critical asset, their patient data. Much of the discussion has centered around ways to deal with a virus infection, such as application whitelisting, restoring a backup, and antiransomware protection. However, as the saying goes, an ounce of prevention is worth a pound of cure, and one item that is often overlooked but incredibly critical to this process is a firewall.

Data flows into and out of devices, such as your router or modem, through what we call ports. A firewall is what controls what is—and more importantly isn’t—allowed to pass through those ports. You can think of it like a security guard standing at the door, checking the ID of everything that tries to enter or exit.

For most normal computers or office networks, the firewall should allow very little, if any, inbound traffic. There’s rarely any legitimate reason for other devices to need to connect to your device, or office network, unsolicited.

Firewalls can be either software or hardware, and most likely you’re being protected by both. The router (sometimes called a cable modem) that brings the internet from your internet provider to your home or office is usually a hardware firewall. And your computer, whether it’s running Windows or macOS, most likely has a software firewall running.

However, what I highly recommend for all dental offices is that they consider a business-class firewall. One of the primary reasons a business-class firewall is better than a consumer-grade firewall is the advanced security features it offers. Business-class firewalls are designed to protect against a wide range of threats, including viruses, malware, phishing attacks, and ransomware. They can also detect and prevent more sophisticated attacks,
such as advanced persistent threats and zero-day exploits.

Business-class firewalls offer a variety of security features, such as intrusion prevention and detection, deep packet inspection, and advanced malware protection. These features are critical for protecting sensitive data and preventing data breaches. For example, deep packet inspection allows the firewall to analyze the contents of network packets and block traffic that violates security policies.

They also offer centralized management, allowing your information technology (IT) provider to configure and monitor the firewall from a single console. This makes it easier to manage network security across multiple locations and devices. Consumer-grade devices may require individual configuration, making it more difficult to manage and monitor network security.

Centralized management also allows for more efficient security management. For example, your IT provider can create and manage security policies from a central console, ensuring consistent application of security policies across the entire office. This helps to ensure that all devices on the network are properly secured and reduces the risk of security gaps.

A good firewall for a dental office, from a company like Sophos, WatchGuard, or SonicWall, is a great investment in your overall security and Health Insurance Portability and Accountability Act compliance plan. While a bit costlier than consumer firewalls, the added protection is well worth the cost, in my opinion.

A key aspect of securing patient data is a powerful firewall. Here we explore the best ways to build up a strong firewall for your dental practice. 

Building a Strong Firewall for Your Dental Practice

Crown preps (and the unexpected challenges they can present) are among my favorite procedures. I love the test of turning my focus to a single tooth for an hour or 2. In our office, we commonly talk about striving to make each one the “best crown ever”—prep design, hemostasis, impressions, temporaries, crown fit, occlusion, and cement all play a role in trying to achieve this.

Implant selection may influence overall clinical success, especially when immediate loading is required. As implants under function have the predominance of load in the crestal portion of the ridge, the bone thickness plays a significant factor in maintenance of that aspect of the bone-to-implant contact (BIC).

 The majority of loading under function occurs at the crestal portion of the implant.

 The thicker the crestal bone around the implant, the better the load handling and preservation of this critical bone over time. Frequently, the thin buccal crestal aspect of bone adjacent to the implant resorbs, which may contribute to soft tissue recession and resultant esthetic compromise. Given time, this may progress to peri-implantitis and compromise the health of the implant. The thicker the crestal bone at the buccal/lingual dimension and between implants or the implant and adjacent natural teeth, the easier it is to preserve that critical crestal bone long term.

 Typically, when the tooth has been or will be lost to periodontal disease or the site has healed, the ridge width at the superior aspect of the ridge is narrower.

 This often results in thin bone thickness adjacent to the implant’s coronal aspect, which has the potential to resorb over time, or is related to homecare issues leading to peri-implantitis and other complications. Soft tissue thickness crestally also plays a factor in bone maintenance with a higher incidence of crestal bone loss reported in
thin biotypes.

Implant design plays a factor with how thick the crestal bone and soft tissue are following implant placement. Platform switching between the implant and abutment has been used to increase soft tissue thickness and aid in preservation of both the hard and soft tissues long term. Traditional implants may result in thinner tissue whereas an implant design that has a platform switch within the crestal portion of the implant will be apical to the implant’s platform. Maintenance of crestal bone is important to long-term success of the implant.

Clinical Benefits of the PRAMA Implant

The PRAMA implant (Sweden & Martina, Due Carrare, PD, Italy) addresses these issues by design, positioning the implant’s platform more coronal than traditional bone level implants (

). This decreases the potential for peri-implantitis by placing the platform more coronal to the biofilm and, therefore, associated bacteria are further from the crestal bone. The PRAMA implant is available in 3 body types designed for use in different bone densities (

). The PRAMA style has a flat self-tapping apex allowing better penetration ability with excellent primary stability. The PRAMA RF (root form) has a rounded apex with a tapered morphology designed specifically for the maxilla and lower density bone clinical situations to create maximum stability due to osseocompression upon insertion into the osteotomy. It is suitable when a crestal sinus elevation will be performed as part of implant placement. The PRAMA SL has deeper, more aggressive threads and is designed for use in less-dense bone (type 3) or in immediate placement into extraction sites to achieve higher BIC and implant stability. The design of the PRAMA neck being parallel in profile allows thicker bone crestally than standard designs with a flared neck (

Bone density plays a factor and correlates to the implant’s thread design. This is especially true in the less-dense bone of the maxilla. Immediate implant placement at the time of extraction has the potential for less BIC, so that thread design plays an important factor in initial implant stability.

 The implant’s thread design correlates to bone density at the time of placement and the deeper the threads, the greater the contact with the socket walls in immediate placement situations. This also plays a factor in implant placement in healed sites, especially in the less-dense bone of the maxilla. Sharper threads provide a self-tapping feature in bone of any density, increasing initial stability with higher insertion torque, permitting immediate loading.

The PRAMA implant is available in 3.8-mm, 4.25-mm, and 5.0-mm diameters with a platform switch to 3.40 mm at the top of the platform in each of the
3 diameters. The hyperbolic curve of the neck has different dimensions, according to the implant diameter (

). This standardizes the restorative components used. With maximizing crestal bone around the implant’s platform in mind, the PRAMA implant is designed with a slight platform switch at bone level or slightly subcrestal upon placement. The neck design provides the surgeon with the option as to placement depth depending on the clinical situation that presents with available neck heights of 1.80, 2.80, and 3.80 mm (

). The concave neck design provides what has been termed bone platform switching, to preserve additional marginal bone beyond the platform switch.

The neck design preserves a ring of marginal bone, reducing stress on the crestal cortical bone. This prevents vascular compression while preserving the peri-implant soft tissue. The implant-abutment connection additionally provides a platform switch with a smaller diameter coronal to the crestal bone. This provides increased space for biologic width, limiting potential bone resorption while stabilizing the soft tissue, ensuring papilla esthetics and its maintenance.

The PRAMA neck has microthreads, which are ideal for soft tissue attachment following healing and also permits osseointegration when in contact with hard tissues, thus making tissue management easier in post-extraction sockets and irregular crests (

). Moreover, it offers the option of a deeper insertion of the implant when needed. Those microgrooves provide mechanical stimulus to help preserve marginal bone, increase the surface area of the implant, and offer the ability of an implant to resist axial loads. The addition of microgrooves on the concave neck provides a bone-preservation strategy, serving a biomechanical purpose to increase implant surface area, reducing stress while promoting crestal bone maintenance under functional loading.

 The enhanced bone volume cervically provides greater resistance to bone resorption, reducing overall stress on the crestal cortex. The strategy of a platform switch and thicker crestal bone around the neck optimizes bone resorption resistance, stabilizing both hard and soft tissue. Additionally, when placing adjacent implants and the mesial-distal space is limited, the concave neck allows for thicker soft tissue, aiding in preservation of the interdental papilla and esthetic maintenance. A frequent occurrence when implants are placed at bone level may present with crestal bone loss over time following restoration of the implants (

). When compared with standard implants, the platform switch afforded by the PRAMA’s design provides thicker hard and soft tissue crestally, which will improve the stability of those delicate tissues (

 Implants with a convergent abutment profile favor axial development of peri-implant connective tissue. Moreover, the microthreaded surface of that convergent neck has been associated with denser and greater connective tissue organization, which may improve the peri-implant soft tissue seal.

Bone loss may result crestally depending on the position of the implant in relation to the crestal bone. Factors that influence that are implant-abutment connection design, implant geometry, implant position, bone density, surface finish material of the implant, and micro gap. Subcrestal implant placement results in greater distance from the implant platform to the crestal bone coronally on the implant. A study reported that mean crestal cortical bone thickness values at the dental implant sites were 0.93 ± 0.75 mm in maxilla and 1.44 ± 1.15 mm
in mandible.

Gingival stability around the implant relates to several factors, including gingival health related to the absence of inflammation and gingival thickness. Thin soft tissue crestally has a tendency to recede (migrate apically) and this becomes more important in patients with thinner soft tissue biotypes. That thinner soft tissue is also more prone to gingival inflammation. The goal to soft tissue maintenance and its underlying hard tissue crestally is creating a thicker gingival cuff to provide tissue stability.

RAMPA (Italian for ramp) refers to the soft tissue’s coronal migration during healing related to the concave (convergent) neck of the PRAMA implant. The convergent neck permits development of thicker gingival soft tissue as healing occurs following implant placement (

). The PRAMA’s microthreads on its neck give the collagen fibers of the gingival tissue an anchorage point on the implant, providing tissue stability. The result is coronal migration of the gingiva, a “ramping” up the convergent neck of the implant (

). The design of the neck allows maintenance of biological width due to the thicker soft tissue and crestal bone long term (

). Thus, esthetics is maintained long term.

Marginal bone loss is also minimized due to the thicker crestal bone when the implant has a convergent neck.

 This decreases the potential for peri-
implant changes that may result when thinner crestal bone is present at the implant’s coronal aspect. A study reported that less peri-implant bone loss occurs around supracrestal implants with convergent transmucosal morphology than implants with parallel or divergent transmucosal morphology.

The use of PRAMA’s transmucosal implant creates a shift of the inflammatory cell infiltrate away from the crestal bone level, thereby decreasing peri-implantitis potential and resulting in better long-term stability of hard and soft tissues.

 Results of a cohort study of 66 PRAMA implants during the 3-year follow-up showed that the implants were stable and free from complications. They indicated a high pink esthetic score and low percentage of bleeding on probing.

 This was supported by another study of 120 implants placed in 53 patients where the PRAMA implant exhibited less peri-implant bone loss than bone level implants regardless of the type of prosthesis used.

A patient presented with a maxillary lateral incisor with failing endodontic treatment performed in the past and hypereruption of the tooth (

). The tooth was extracted, and an immediate PRAMA SL implant (4.25 mm x 10 mm) was placed. Sufficient insertion torque was achieved. A healing abutment was placed and radiograph taken to document placement in relation to the adjacent anatomy (

). An immediate provisional restoration was fabricated, and the soft tissue positioned in a more coronal direction to correct the recession that had been present on the natural tooth (

). The provisional restoration was adjusted to be out of occlusion in all positions to avoid any hampering of osseointegration.

Following a 4-month osseointegration period, the patient was deemed to be ready for fabrication of the final restoration. The patient presented with healthy soft tissue with elimination of the pretreatment recession (

). Removal of the provisional restoration noted healthy soft tissue around the implant’s neck and RAMPA effect had occurred (

). An impression was taken and the lab fabricated the final restoration. Upon insertion of the final restoration, a periapical radiograph was taken demonstrating stability of the crestal bone as compared to the radiograph taken at insertion (

A patient presented with a coronally fractured maxillary premolar following loss of the existing crown. A radiograph was taken to evaluate the tooth (

). The tooth had prior endodontic treatment and was deemed structurally inadequate to restore the tooth due to lack of any coronal tooth structure. The patient was recommended immediate implant placement following extraction. If adequate insertion torque was achieved, an immediate provisional restoration would be placed.

The tooth was extracted under local anesthetic and a PRAMA implant (3.8 x 10 mm with a 2.85-mm neck) was placed at the level of the crest post extraction following osteotomy preparation (

). Although 45 Ncm insertion torque was achieved, it was decided not to provisionalize the implant and a healing abutment would be placed and a radiograph taken (

). A healing abutment was placed, and a radiograph taken to confirm full seating of the healing abutment at the implant’s platform (

). Allograft that was 50% cortical/cancellous graft material was placed into the coronal aspect of the socket around the healing abutment and the site sutured to contain the graft material (

). An OsseoGuard RCM membrane (ZimVie) was placed over the extraction socket with poncho technique using healing abutment.

The patient presented at the 4-month recall appointment and the implant was deemed ready to restore. The healing abutment was removed, and a healing gingival cuff was noted with RAMPA effect present (

). An impression was taken and sent to the lab for fabrication of the restoration. The final restoration was returned to the practice and inserted into the patient. A radiograph was taken to verify restoration seating at the implant’s platform (

). When the radiographs taken at implant placement are compared with the post-restoration radiographs, the crestal bone is noted to have maintained the same position, demonstrating the stability the PRAMA neck provides to hard and soft tissues.

The concave design of the PRAMA implant with its microgrooves allows for thicker crestal bone and soft tissue that improves maintenance of those surrounding tissues.

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Nimbalkar S, Dhatrak P, Gherde C, Joshi S. A review article on factors affecting bone loss in dental implants. 

. 2021;43(part 2):970-976.. Accessed September 9, 2024. https://www.sciencedirect.com/science/article/abs/pii/S2214785320355383

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Critical to an implant’s long-term success is tissue stability. We take a deep dive into implant design and how to improve maintenance for implant success.  

Clinical Benefits of the PRAMA Implant for Improved Soft and Hard Tissue Maintenance 

Plenty has been written about Shofu Dental Corporation’s bioactive Giomer Technology in the past years, but many clinicians may not yet know exactly what it is and why materials incorporating these benefits can be a great way to restore patients’ smiles and to do so for a long time.

The dental company has released a line of products featuring Giomer Technology, including Beautifil II Nano-Hybrid Universal Composite, BeautiLink SA, and Beautifil KIDS SA. Here, Shofu answers a series of questions from 

designed to explain how this unique technology benefits dental materials and patients and to answer any questions clinicians may still have about Giomer Technology.

Explain what Giomer Technology is and why it helps Shofu products stand out compared with other products available in the market.

Shofu: Giomer Technology is a proprietary filler particle engineered and manufactured by Shofu Dental for use in our restoratives, preventatives, and cements. Unlike inert products created by other name-brand competitors, Giomer products have been proven in numerous clinical and laboratory studies to reduce secondary caries, neutralize acid, minimize sensitivity, and strengthen tooth structure through their release and recharge of fluoride and 5 other healthful ions for the life of the restoration. For decades, Shofu has been the leader in the advancement of bioactive dental materials to fulfill our mission of helping clinicians to “create healthy and beautiful smiles all over the world.”

Tell us about the process and the research and development of this technology.

, or teeth blackening, was common in Japan from the 1600s to the mid-1800s. It is believed that the ingredients used in this practice effectively prevented tooth decay, making it the pioneer of bioactive materials. By the mid 1800s, Japanese people no longer practiced this treatment, but still had the desire to have healthy teeth. Over the decades, many dental companies have tried various technologies and additives to achieve this purpose. Fast forward to the 1990s, when Nakatsuka, et al of Shofu’s Research and Development Department created the Giomer particle, which could be used as part of the filler for resin-based dental materials to offer clinicians a healthful alternative to numerous inert competitors.

Why does Shofu Dental feel it is important to offer products that provide a bioactive and therapeutic alternative to other, traditional restoratives?

Shofu: Since Shofu’s mission is to “create healthy and beautiful smiles all over the world,” we enable dentists who use Giomer products to enhance their patients’ smiles and promote the longevity of their teeth. Secondary decay, which is caused by bacterial infiltration and accumulation at the restorative margin, is the main cause of restorative failure.

Clinicians who choose products that are clinically proven to significantly reduce secondary decay also reduce the likelihood of restorative failure, thus improving the durability of their work.

In recent years there is a greater acceptance that good oral health contributes to good systemic health. Chronic health conditions such as endocarditis, cardiovascular disease, Alzheimer disease, diabetes, and many others are statistically linked to poor oral health.

 This “oral-systemic link” continues to be proven stronger every year as additional studies are released. This is why it is so important for clinicians to consider these materials for clinical use.

These ions have been clinically proven to inhibit plaque, neutralize acid, and eliminate secondary decay. Please share any key findings from clinical studies as well as Shofu research explaining the bioactive and therapeutic benefits of Giomer Technology products.

Shofu: Based on the technical knowledge of each element, the bioactivity of each ion listed below is well known in dentistry and medicine. Here is a list of the individual ions released and recharged by the Giomer particle with the healthful features of each.

During the initial stage of developing Giomer, it was assumed that each ion would independently produce the bioactive effect listed above. However, after exhaustive clinical research, additional bioactive effects were realized due to the synergistic effect of the 6 ions. We have resources listed on our website, Shofu.com, or you can Google Giomer studies to review the studies and learn more about the healthful benefits of Giomer.

How many Shofu products include this technology and what cases are these materials indicated for?

Shofu: Shofu’s composites all feature bioactive Giomer Technology. We also offer cements, a desensitizer, and a sealant that incorporate this innovative technology.

There are 2 nano-hybrid universal composites: Beautifil II and Beautifil II LS. Both offer superior strength and polishability. The unique filler structure combines the light transmission and diffusion properties of both dentin and enamel to blend with the surrounding dentition. The esthetics make them ideal for anterior restorations, and the high filler load, wear resistance, and low shrinkage make them strong enough for posterior restorations. The main difference between the 2 universal composites is the handling: Beautifil II has a smooth consistency, while Beautifil II LS has a firm consistency.

Beautifil II Gingiva is a specialty composite available in 5 gingiva shades, which can be layered and blended to create custom gingival shades for all ethnicities. This composite is designed to improve gingival symmetry, repair recession, and disguise exposed crowns and bridges margins and implant abutments. Additionally, Giomer Technology may enhance tissue response and periodontal health in Class V restorations and noncarious cervical lesions.

Beautifil II Enamel is a specialized nano-
hybrid universal composite offered in 4 unique translucent shades. It is suitable for esthetically restoring cases involving incisal edges, naturally translucent dentition, enamel loss, composite veneering, and other complex cosmetic cases.

Shofu has 2 nano-hybrid flowable composites, Beautifil Flow Plus and Beautifil Flow Plus X. These products are quite similar and are for all restoration classes, including occlusal and cusp. Beautifil Flow Plus was the first flowable composite to receive FDA approval for use on restorative Classes I to V. Both composites offer better compressive strength and wear resistance than many leading universal composites. They also have similar light transmission and diffusion properties to our universal composites.

Beautifil Flow Plus and Beautifil Flow Plus X are available in 2 viscosities: Zero Flow and Low Flow. The Zero Flow (F00) provides excellent shape retention and accurately restores occlusal morphology without slumping, while the Low Flow (F03) thoroughly wets the cavity walls and offers superior adaptation. The main difference between the 2 is that Beautifil Flow Plus X is the newest version, which features improved polishability and handling.

There are 2 self-adhesive flowable composites: Beautifil Kids SA and FIT SA. Both have eliminated the technique-sensitive bonding procedure. Beautifil Kids SA is ideal for preventive resin restoration and small Class I restorations, while FIT SA F10 is used as a liner.

BeautiSealant is a pit and fissure sealant that does not require acid etching, saving time and money. It offers superior bond strength for long-term durability and features BPA- and HEMA-free chemistry.

BeautiLink SA is our newest addition to the line of Giomer products. This unique self-adhesive resin cement is a dual-cured product specifically designed for zirconia restorations, which are the standard material for today’s crowns. Giomer Technology reduces the caries-causing bacteria in the preparation or infiltrating the margins, greatly reducing the No. 1 cause of crown failure.

Finally, PRG Barrier Coat is a light-cured, resin-based desensitizer that is the ultimate solution for prolonged desensitization. It blocks occludes and protects the dentin tubules from external irritants for up to 6 months.

What has been the feedback from clinicians using these products?

Shofu: The doctors who use our products have given very positive feedback. They have mentioned that the products are easy to use [and] look great, and their patients do not experience postoperative sensitivity. They appreciate the bioactive Giomer Technology, which significantly reduces secondary decay and the need for redoing their restorations due to failure from bacterial infiltration. In addition, Giomer Technology products have received multiple awards and recognition from independent organizations, including The Dental Advisor, Catapult, and Dental Product Shopper.

This technology appears primed to have a significant impact on dental restorations going forward. What does Shofu see with this technology going forward and just how impactful might these materials be in the future?

Shofu: Shofu’s R&D constantly explores how Giomer Technology can be used in other products. We anticipate a few new products coming in the next few years. As time goes by and the benefits of the bioactive Giomer Technology continue to be more recognized and accepted, it will become increasingly clear why doctors should use these types of products that benefit their patients.

Elaborate on some of the esthetic benefits and how the unique filler structure gives Giomer restoratives the light transmission and diffusion properties of both dentin and enamel to blend well with surrounding dentition without the need for complex layering techniques required by many competitors.

Shofu: With its exceptional light transmission and diffusion properties, this material offers superb shade-matching capabilities. The chameleon effect successfully replicates the internal structure of natural teeth, virtually eliminating complex layering techniques to simplify the placement of composite restorations. Clinicians have told us that the reduced procedure time and reduction of composite inventory has made their practices more efficient. This is especially beneficial to dental service organizations, health centers, dental schools, and practices who accept insurance.

In conclusion, Shofu believes that Giomer products should be available and affordable for all dentists; therefore, they are available from virtually every dental distributor at prices that are typically 30% less than most other name brands.

1. Mjör IA, Moorhead JE, Dahl JE. Reasons for replacement of restorations in permanent teeth in general dental practice. 

2000;50(6):361-366. doi:10.1111/j.1875-595x.2000.tb00569.x

2. McMains V. Healthy mouth, healthy body. National Institute of Dental and Craniofacial Research News. May 8, 2024. Accessed September 5, 2024.
https://www.nidcr.nih.gov/news-events/nidcr-news/2024/healthy-mouth-healthy-body

The dental company has a comprehensive line of products that take advantage of this materials technology to assist clinicians striving to deliver good-looking, long-lasting restorations.

A Close Look at the Benefits of Shofu’s Giomer Technology

has a section devoted to coverage of the 2024 Cellerant Best of Class Technology Awards. You’ll find a full listing of the winners along with descriptions of the products as well as some reasons from the panelists on why they voted as they did.

However, you may be asking yourself, “Why does one more dental award matter?” and I’d like to take some time this month to explain just that. After all, there are several awards given out in the profession each year, so why are the Cellerant Best of Class Technology Awards special? Allow me to explain.

The program began back in 2009 when Cellerant Consulting Group founder and CEO Lou Shuman, DMD, CAGS, had a vision for an award to provide recognition to companies that were developing leading-edge products for the profession. Originally it was called the Cellerant Best of Class Technology Award, and the focus was tech centric. However, shortly after the award’s inception, the group quickly realized that there were many other companies and products that deserved recognition for cutting-edge materials and devices that fell outside of the technology category. This gave birth to the current wide scope of product considerations.

The panel is composed of prominent technology leaders in dentistry. They are Dr Shuman, Paul Feuerstein, DMD (editor in chief of 

), Pamela Maragliano-Muniz, DMD (chief editor of 

), Marty Jablow, DMD (“America’s Dental Technology Coach”), Chris Salierno, DDS (chief dental officer of Tend), and myself.

As both technophiles and doctors, the panel members approach the voting process by considering what we would purchase for our practices to help give our patients the best care and best results possible. By putting ourselves in the shoes of the doctors who benefit from our selection, we hope to help the profession and the patients we serve.

The awards require a rigorous nonprofit, impartial process and that is exactly the way it happens.Every year the panel meets to talk about products that have impressed them. There are no guaranteed categories, ensuring the panelists are free to bring up any product they feel has made or is poised to make a significant impact on the profession. Each product is discussed and debated. Not all nominees win, even if they are the only product considered for a category they cover.

Occasionally a product from the previous year continues to impress and again is recognized with an award. This lets the industry know that the product has still met expectations and has a track record of success.

Chief dental and technology editor John Flucke, DDS, gives an in-depth look at the annual Cellerant Best of Class Awards, from their history to the decision-making process.

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