.jpg)
Dentist2Dentist
Join Dr. Mike Miyasaki as he talks dentist to dentist about the trends, products, and clinical applications in dentistry today.
Dentist2Dentist
Revolutionizing Restorative Dentistry: Harnessing Bioactive Materials for Healthier Smiles
Embark on a journey through the transformative landscape of bioactive materials in dentistry, where tradition meets innovation at the intersection of health and science. Discover the remarkable evolution of dental bonding systems, as we trace their origins from the revolutionary fourth generation to today's cutting-edge adhesives. Our exploration doesn't stop at historical milestones; we also shatter common misconceptions and advocate for a more holistic approach to adhesion, thanks to insights I gained while working with pioneers at Apex Dental Materials.
The conversation turns to the dynamic realm of bioactive properties and their promising applications in restorative dentistry. Imagine materials that mimic the natural process of bone formation, enhancing tooth remineralization and providing a formidable defense against secondary decay—this is not the stuff of fiction but the remarkable reality of bioactive glass and its derivatives. We dissect the mechanics of these materials and their symbiotic relationship with biological tissues, showcasing a future where dental restorations not only repair but also regenerate.
Wrapping up, we provide a masterclass in the practical application of these revolutionary materials. Through a meticulous step-by-step guide, learn how to harness the power of Desensimax and Regen products for superior clinical outcomes. We also proudly introduce pulse activation, my personal innovation that minimizes post-operative sensitivity, redefining the standards for composite restoration techniques. By integrating bioactive materials into your practice, you're not just restoring teeth—you're fortifying the future of oral health.
Good evening. This is a lecture about an introduction to bioactive materials using bioglass and how they fit into dentistry and how they fit into dental materials. But first a little bit. Here's sort of our agenda for today. We're going to talk a little bit about history. I'll talk about the birth of the fourth generation of bonding systems, as that now is referred to as the golden standard for adhesives, then we're going to talk a little bit about apex resident adhesives, and we'll talk about simplicity, surpass, and then we're going to talk a little bit about misconceptions before we move on to some other things.
Speaker 1:In 1988, we saw the birth of the fourth generation of bonding systems. This included treatment of dentin and enamel with phosphoric acid, followed by use of tenurean B, which is something I liked at the time. We applied that to the edge surface and followed it with Scotch bond 2 resin for light cure systems and Scotch bond dual cure when bonding in crowns. This was published in the Journal of Ascetic Dentistry in 1989. This later became a commercial product that was known as all bond and all bond 2. That was the embodiment of this particular system. From this we now treat dentin and enamel with a good enough acid to create proper enamel etching and then dentinal treatment as well. I became a part of Apex dental materials in 2001 and we formed immediately something that had been percolating in the back of my mind. It ended up being a product called simplicity. Simplicity was two parts. It was a treatment of fer acid and dentin that was not rinsed off, followed by a resin. It's amazing to me that this is now 20 years old, but there it is and it's still a functional adhesive.
Speaker 1:In 2004, I began working on another project and there was going to be a no-rinse version of the fourth generation systems, in other words, something that would be the gold standard. That's what I sought to create. Was that gold standard for no-rinse materials? That was Surpass. Surpass is still one of the best adhesives that you can find on the market. In 2008, I took this to the University of North Carolina. I took it to Tufts and two-hour bond strengths that we had with the accelerated aging showed 55 MPa. And in 2008, I took it to CRA, now known as CR. We generated 38 MPa and we had bond strengths, which were, and are still, very, very high bond strength numbers.
Speaker 1:You may not have heard much about this. If you haven't, I would simply point to the people who were at these universities, at these institutions, and ask them why you haven't heard about that. In 2013, apex, we created another adhesive, a universal adhesive called superb. Now you might notice that all of the adhesives so far began with an S, and that is by intention, because once we got the first two, the third one we said we have to continue the process.
Speaker 1:Now, superb is a little bit different than simplicity in that this can be used with an acid etching. It can be used with actually can be used with a surpass one, but we're not going to get into that right now. This is meant primarily for use as a phosphoric acid treated dentin and enamel first, followed by the application of superb. It will stick to everything, just as surpassed. Surpass is universal. Every kind of bonding, every kind of adhesive or composite sticks to it, and with superb, every kind of composite sticks to it, whether it's self-care, like-care, dual-care, everything will stick to it.
Speaker 1:Now I'd like to clear up some common misconceptions that I learned at a meeting not too long ago and as I sat there listening, they came to me and I would like to clarify them right now, and one of them was that etching. There is no. Really there is no such thing as over etching, because what happens? You know, you're going to be putting phosphoric acid on a tooth, an enamel and dentin for a period of somewhere between 15 and 30 seconds and that is not going to present a problem for anybody's adhesive. In real reality there is a possibility of over etching, but you've got to go out to like three to five minutes of constant replenishing phosphoric acid before this really becomes a clinical issue. But between you know, 15 to 30 seconds, this isn't going to be a problem, you know, especially if you're just leaving the phosphoric acid in place as it reaches an equilibrium in a steady state and it doesn't continue etch after a while Two.
Speaker 1:There is no such thing as resin incompatibility. All resin composites will stick to all adhesives. The only exception to this is that some self-care materials will not stick to some particular adhesives which are a little tend to be a little bit more acidic in nature. But from a light activated standpoint, everything will stick to everything else because the vinyl ends on all these molecules and it's all vinyl polymerization. All the ends of these monomers are the same, so they will stick to one another, certainly in a light-care environment. And then we have the nonsense known as selective etch.
Speaker 1:This, to me, is what I've been calling the great leap backward, because this is something I tried to extinguish about 30-something years ago, trying to get rid of this. Because what happens is people try to put acid. They say they're putting acid on just the enamel only and not treating it in the dentin. But if you look carefully at this you'll see that that's kind of hardly the case. I find it rather amusing to see these cases like this and like this and say, oh my goodness, we're just putting acid on the enamel, but that doesn't happen. You're putting acid on a dentin and were you putting it on a dentin, in particular at the most vulnerable portions and that is, in the proximal boxes and along these deep margins, and if it was going to adversely affect the dentin, that would be the worst possible place to affect the dentin. So to me this is just a joke. Now we're going to put fast work acid on dentin. We put it on dentin and be done with it. We can deal with it and make it work and it's not a problem.
Speaker 1:The other thing we have to know is that the durability of the bondin interface is dependent on solvent evacuation, in other words, in your bonding systems, there will be one element that has a solvent in it usually alcohol or acetone and it is critical that that alcohol or acetone be evaporated from that bonding system when it's on the tooth Now, and all of these materials are meant to be placed on a moist or wet tooth. So now you're going to have the solvent, alcohol or acetone, you're going to have water present on the surface and you have to remove this diligently. You have to dry this thoroughly to make sure all the water and all the solvents are evacuated, and that will allow you to have a long-term durable bond. And here's one of the studies that looked at this, and it says here alternatively, complete removal of water from the hybrid layer with and this is ethanol with bonding. But removal of the water from the hybrid layer is critical to making bonding work. And so, whatever we are using, whichever portion has the alcohol or acetone in it, once that's applied, the surface must be really, really thoroughly dried, and that understanding has allowed us to offer you something like surpass, which is shown to be extremely stable over a long period of time. Now, this particular investigation went out to three years, but we've looked at this, I've taken these out to five years and seven years without any measurable or significant loss of bond strength.
Speaker 1:Now I wrote an article in dental learning in a magazine and it was taught it regarded bioactivity and what bioactivity is and the history of it. So we're going to kind of go over this a little bit at a time. We're going to define bioactivity, share something about the history, what Bioglas does for you, then we'll look at the next generation of materials that are going to be available in dentistry and then in the marketplace. Now bioactivity refers to any material that has the potential to induce a response with living tissues, but it has to be living tissues. And there are two phases in bioactivity. There's an inorganic phase and an organic phase. If you try to do this, as you're going to see, in vitro, all we can get to is the inorganic portion of this. We can't get to the organic portion, which only occurs in a human being, in biologic fluids, and it is specifically biologic fluids that induce these activities to take place. So we're going to kind of look at that now.
Speaker 1:Bioglas has been around since the 60s and it's a synthetic material that has been verified to stimulate the creation of an appetite. Materials hydroxyapatite and bone-like materials. There have been a lot of materials in the market which allege to be bioactive, but they're not really. They only get partway there when you have an inorganic response, an inorganic change. These are only. This is not really bioactivity, it's just an inorganic response to these materials. So whether they're glass ionomers, resin, modified glass ionomers, gmers, these are not bioactive materials in the sense that in the actual definition of the material Now bioglas, whatever it refers to, it goes by the name of it in bioglas and nomenon and what this does.
Speaker 1:What this refers to here is the makeup of this. We have 45% silicon dioxide, about 24.5% calcium oxide, 24.5% sodium oxide and 6% by weight of potassium pentoxide. So this is what makes up bioglas and what's interesting about this. You start adding little bits of materials here and they're changing the proportions and you get some very interesting things happen. Ironically, this is not terribly different than the window glass that you have and they just change it. There's a little bit less silica, there's higher amounts of calcium and phosphorus in these things, but again, it seems amusing, but it's not terribly far removed from window glass. Now, the 45S5 name refers to the 45% weight of the percent of silicon dioxide and the 5 to 1 molar ratio of calcium to phosphorus. It is that ratio, and it's particularly that ratio that promotes the formation of appetite crystals and allow the rest of the reactions to take place. Lower calcium phosphate ratios do not stimulate bone formation or bone to bone. Now this is very important.
Speaker 1:Bioglas's ability to be integrated with bone kind of reflects its similar makeup to bone and hydroxyapatite. And hydroxyapatite might sound familiar to you. Larry Hensch was at the University of Florida in the late 60s and he was working on radiation resistant materials and he was looking because this is during the Vietnam War and people were getting some debilitating and severe injuries. He was looking at the development of material that would bond to bone and the funding began in 1968 and began synthesizing rectangles of I didn't call it bioglas, but it was 45S5. And he kind of eventually found out that this material that he developed was osteoconductive and bioactive. The first use for bioglas was for ossicles in the inner ear and then since then copper, zinc or strontium kind of are added in little amounts and different amounts to stimulate bone formation or, again, hydroxyapatite formation.
Speaker 1:Now if you look at this particular diagram, what it shows, if you take the bioactive glass, there's a process that occurs, that causes the release of materials, of solenols, to form around in a biologic fluid. Now an important statement here this is in biologic fluid and it causes a silica gel to form around the bioglas crystal itself and then that attracts calcium, phosphate and carbonate to it. Ultimately, cells begin to become attracted to it. Now this is the biologic process right here Up to here, in this portion here what we have is the inorganic portion of this, but again in a sort of simulated or biologic fluid. Once we get into the body now we can have other things that take place. Cells begin to form here, which goes through collagen formation and then ultimately that mineralizes into bone. This is how bioglass works in the body when you're looking to repair or bond to bone.
Speaker 1:Now in the mouth it's a little bit different, but similar bit different. In the mouth we're looking for, you know, you have alkali ions in on the glass again, which cause once when encounters vitally fluids or biological fluids causes the hydrolysis of silica groups which are in the bioglass and then soluble silicon silanos form around the glass in again in the body and in biologic fluids the silanol groups condense on the surface and that's the gel that you saw back here that you saw the condensing on that surface. And again this is attracted. Calcium, phosphate carbonate are attracted to form carbonated hydroxyl appetite. This is the, basically the inorganic. You can reproduce that in a lab and we have done that. Then you have the absorption of growth factors to bioglass. Then you get stem cells forming healing response and then you get osteoblast formation. Then they form collagen and collagen goes on and mineralize and form hydroxy appetite and that's how this kind of all works. So we have we're looking for remineralization and strengthening of two structure. We're going to have fluoride release, we're going to have calcium release, phosphate release. The potential is here to form appetite like materials on the surface. Now you'd be looking for this to occur on partially demineralized areas and very, very importantly, on the margins of restorations, in particular resin restorations which suffered degradation so very frequently on the interfaces. But here you have the ability to sort of create an environment which could actually potentially repair defects in these particular areas, so sort of looking to regenerate live tissue and promote again vitality in these teeth. Bioglass has some very interesting properties and inhibits bacterial growth, which is kind of cool. It will reduce microbial counts in the environment in which it's located and has the potential to do wonders in periodontal regeneration.
Speaker 1:If again, if we look through history, we start to see some of the things that we had here In the 1970s saw the advent of glass ionomers, when we had fluoride release from these glass ionomers. But this again, this is an inorganic reaction. In these teeth it forms a bit of fluorapetite, can harden enamel and dentin a little bit, but that's inorganic, because it was, it really shown, necessarily prevent secondary decay Once the fluoride ran out. I mean, in some cases you could recharge it, but once the fluoride sort of ran out it wasn't really that great against secondary carriers. Then we had resin modified glass ionomers show up in the 80s and again there was again it's sort of claimed by our activity but it's not. It's the inorganic phase of that and really didn't offer true bioactivity. Some releasing cements were sort of kind of getting there but didn't get there. Bioactive resins we saw again released about 2013, but not again not really up to the job. Gmrs again, which GMR is? Most people don't know what this says, but GMRs are reacted glass particles which are ground up and then use this fillers in resin. That's what a GMR is and again, does it really do what you want it to do and the answer is no.
Speaker 1:In 2017, we saw the introduction of alkocytes. Alkocytes are alkaline fillers put into sort of a powder liquid resin matrix, if you will and can these things. These are pretty darn good at resisting secondary decay. They are not a substitute for composite resin. They're not a substitute for amalgam, as has been suggested in the literature. But it's not going to wear like either a composite or an amalgam, because this is powder liquid and anything that's a powder liquid is not going to wear as well as a really highly filled material like a highly filled paste, composite or amalgam itself.
Speaker 1:In 2020, 2019, 2020, we started actually creating. We brought in the use of bioactive materials and we started to create a suite of materials and that's what we're going to get in here in a minute. This is just kind of a little bit of nitty gritty here. In the alkocytes they have alkaline fillers. They lowered the sodium oxide, add some calcium fluoride. It's a powder liquid. As I said, it's not really a substitute for amalgam. It's not a bad product, but it's not going to be all around useful.
Speaker 1:Now we're going to look at ion exchange. We're going to look at a number of things to see how this actually works in these particular materials we're talking about. One of the things we'd like to see is sustained release of ions from these materials and this is a comparison of the ion release in the Vista products, the Apex bioactive materials, versus a pulp dam product known as Activa, and, as you can see, the fluoride release was continuous and lengthy. And we look at the, this is calcium release. There's a drop-off in calcium release here and it continues on the upward with the bioactive materials from this Apex and here we have phosphate release. So these are pretty similar. So these are similar. But you need all three of these, these ion releases, to affect a good response in these materials.
Speaker 1:Now, as I said, bioactivity has been a label that was placed on a lot of materials, like glass, ionomers, but it didn't include the organic response to this. Once you actually put something in a body, just it was including like, for everybody was really hanging their hats on the development of fluoropathy. But now, with bioactive materials, again we're adding calcium, phosphate ions and we're looking to actually induce a response that could be reparative for these restorations. One of the beauties that we have in here is we have there is a in these suite of materials offered by this Apex. There is we have two bioactive adhesives, and this is important because if you put in, you put in an adhesive which is not bioactive, it tends to act in most cases as a barrier to bioactivity. So we felt that, you know, it would be a good thing if we had an adhesive that was bioactive as well. So it's a continuous line of materials that borders up against the tooth and has the ability to induce bioactivity in these restorations.
Speaker 1:This is a very, very important image that we're looking at right here. These two disks were immersed in artificial saliva for two weeks at 22 degrees centigrade. This one right here let's see if I'll do the cool thing here with this this one is just Titan. That's the flowable composite from this apex. This is called Regen flow. This is the bioactive version of Titan and what's going on here is you can see particles are forming and being deposited, that it's drawing ions from the artificial saliva and inducing a change on the surface here.
Speaker 1:This is hydroxyl carbonated. Hydroxyl appetite is what we're looking at right here, and so this is the beginning of appetite formation, of hydroxy appetite formation. But it can only go so far in vitro because this is immersed in artificial saliva and it's not in the human body. But this is very, very interesting and very, very important. You begin to see how much the contrast between a bioactive material and a non-bioactive material so that gets. We're getting part of the way there and that is a critical thing to know, and that is carbonated hydroxyl appetite. What we're hoping to see, and I think we're going to see, is that this carbonated hydroxyl appetite goes on to become hydroxy appetite in the body, and there was a study done at University of Alabama by John Burgess and his group, and this is a really, really important study as well.
Speaker 1:They cut boxes above and below the denominal junction in teeth that were restored with various materials. These restorations then were placed in a demineralizing solution or artificial carries solution for four hours. So they were challenged. They were challenged in vitro in an artificial carries environment. Then they were placed in a remineralizing solution for 20 hours and cycle daily for 30 days. So then they were taken out and the specimens were sectioned and they were examined. And here's kind of what we got.
Speaker 1:If you look, here's the restorative material over here. Let's go back to the cool laser. Here's the restorative material here. This is the dentin and you can see here, this is the demineralized zone that resulted from the immersion in the artificial carries solution and if you can see a curls up right here, now what this is is right here. What this refers to you can see this is the carries resistant zone right here that has been formed and that is. That's a very positive thing, which it shows. It sort of protects the interface from a carrier's challenge and this indicates that there was a resistance to carries. When you see this kind of response to it, it means that the artificial carries was successful in eroding the interface between these two. So we'll kind of take a look at a couple of examples on this and see what we got and what we have here in this artificial model, artificial carries challenge model.
Speaker 1:This is the adhesive here, this is the, this is dentin, this is the I beg your pardon, this is dentin, this is and we have the composite here. Okay, stop that, okay. So what we have here, this is the dentin, here we have the restorative material and what we've got is a resistant carries resistant zone right here, a very successful carries resistant zone. This one is using the art of the bioactive adhesive and the bioactive composite, the region flow and this forwards a great resistance to carries relative to everything else. Well, we have here this is activa with no adhesive and you can see again, you see how different this is, this one is. You can see this is curled up and what they did was measure this line right through here and then measure the area under this and that became the zone of carries resistance and this is negative. Over here, this is a negative and this was not that effective that resisting the carries challenge. Now, curiously, here is activa with the adhesive and that actually was a better result, suggesting that bonding the active, it to the tooth is a preferential treatment over not putting it on these teams, so sorry. So this, this is kind of an interesting result.
Speaker 1:And here we have this is the, the composite without it's a non bioactive composite, non bioactive adhesive and again, you can see the loss of tissue right here. This is an eroded area. This did not successfully defend against the artificial carries acid attack, whereas over here, with the, with the bioactive adhesive, bioactive composite, this was a successful resistance to it. So this shows you how important this can be in the presence of an artificial carries attack. So what I show you when we look at there is. There is protection in using the composite alone with a non bioactive adhesive. Here's with the adhesive and a non bioactive composite the bioactive adhesive, non bioactive composite. But using the composite itself is very is very helpful, but together this becomes very important. This is a synergistic effect. When the adhesive and the composite are used together, both of bioactive, it affords a great deal of a inhibition zone 240% larger than the non bioactive materials, mature kind of. So again, here's some evidence that on an in vitro basis this does afford resistance to carries.
Speaker 1:And one of the really another wonderful benefit of bioactive materials is the ability to neutralize acid environments. So if we have bacteria adhering to, say, the interfaces of or trying to attach to the interfaces of restorations, once that acid, everything dies by acid attack. Once the acids begin to form, they can be neutralized by the presence of these fillers. And that's kind of nifty and there's a little bit of a video here we're gonna play. We're gonna look at that. So this is non-bioactive, this is bioactive. And now what's introduced is lactic acid to drop the pH below four and you will watch it over time it comes back, as you can see on the Regen filler materials here in liquid. It comes back, it neutralizes it. Now another, have another acid addition here and it will return the pH to over eight, whereas in a non-bioactive material it does not return it, it just stays acidic. And this was done over a period of about an hour, and each time it would return the pH to an alkaline state. So, again, the process of resisting kary's activity is in large part due to the ability of the materials to neutralize the acidic pH is presented by kary's attack Another great benefit, and so and bond strength are not compromised in these materials. We've measured these out and the bond strength are excellent for both dentin and enamel. In each of the materials that we have Now we have a sweet. This Apex offers a sweet of bioactive materials, and here they are.
Speaker 1:This is Regen selfish. For those of you who are surpass fans, regen selfish is the bioactive version of surpass. You're not gonna give. You give nothing up there's. In fact, you get a lot more from this, in that if you use this with the bioactive flowable, this is gonna afford all of the things that we just talked about. All of the benefits that we were just talking about are yours. In using the Regen selfish as opposed to surpass, nothing changes. Nothing in the technique is altered, nothing's lengthened, nothing shortened. It's exactly the same as it was. But you have the benefits of bioactivity within the materials.
Speaker 1:And this is Regen universal, which is the bioactive version of superb, and again, we're gonna talk about how to use this pretty shortly, but this is a, again, a terrific material. If you're using superb, I mean, I would encourage you to use this instead, because this again offers you all of the benefits of bioactivity that you don't have otherwise. Now we have Regen flow, which is the bioactive version of Titan. This is a critically, critically important material. This, in my opinion, should be used in just about every single restoration in place and I'm working on some other projects as well, but this is so, so important.
Speaker 1:And then there is a Regen pit and fisher sealant, a bioactive pit and fisher sealant, which is really kind of nifty. In these cases, what I would recommend is, following cleaning up a tooth, acid etch a tooth and then rinse it and dry it and apply the Regen pit and fisher. If you're placing pit and fisher sealants, just put it in straight away, because then you have this directly in the contact where the tooth. You can, you know, spread it around a little bit and then light activate it. That's the way to go with this material and it's what we use too exclusively in pit and fisher sealants.
Speaker 1:Now I'm going to go over a couple of protocols here. We're going to talk about bulletproof protocols because you know, this is something that people still I guess I haven't had sensitivity as an issue for so long. I sort of forget sometimes. So what we're going to do is talk about a couple of different protocols right here, and bulletproof protocol number one is going to be Regen Universal. What I would say is apply velvet etch to your cavity for 15 to 20 seconds. It can go longer if you have to. It's not going to hurt anything.
Speaker 1:Now this is going to be rinsed away, but I'm going to tell you something about velvet etch. Now. Velvet etch is the purple etch and I'm going to show you a picture of that in just a little bit. The velvet etch is a really, really interesting material. It has a nice viscosity. It stays where you put it. But you can rinse this away with a simple water flow. Just a water rinse out of your air water syringe, just the water will rinse this away in about five seconds. That's all it takes. You don't have to be blasting this with air water, it doesn't need a spritz, it doesn't need any of that stuff, just a water. Rinse on this thing for about five seconds, rinse it dry it. Take a look and see if you don't agree, because you're going to see beautifully etched enamel and everything's dry. That works just perfectly.
Speaker 1:Now what I would encourage you to do is put on a coat of Desensimax, which is the desensitizer Again, we're going to mention this. Put this on with a micro applicator, a teeny little one. Leave it wet. Then we would apply three brush rolls of the Regene Universal and just put them on. And then what you do is dry, hold the high volume suction near the cavity prep and then dry it gently at first and then dry it really thoroughly, because again, you want to drive out, as we talked about. You want to drive out the water and the solvent that's present in the region in all these adhesives. So dry it out, dry out very thoroughly, light cure this for 10 seconds.
Speaker 1:What we're using now is a pink wave, doesn't matter which adhesive. If you're using a turbo setting, it can be done in about three seconds, but otherwise, in standard setting, it's about 10 seconds. Then one or two millimeters of Regene Flow to all of the dentin up to and including the cavo surface enamel or dentin at the bottom of the prep. Bring it up the walls of the axial walls to near the occlusal surface. Then you'll like cure that for about 20 seconds or two of this. If you're using a turbo power, two cycles of three seconds each for about six seconds. The Regene Flow is a little more opaque than is Titan. So Titan light activated very, very quickly, very thoroughly, but this is a little more opaque, needs a little bit more energy to work properly. And then you can add, insert exquisite or whatever composite you're using, then again curing each other for either three seconds or 10 seconds, depending on the power of your light.
Speaker 1:All right, what I'd like to bring to you now, or share with you, are some bulletproof bonding protocols Following these and again, since I've been away from sensitivity as an issue for so long, I sort of forget that some people still have trouble with this. So I want to give you two protocols, either of which, if you follow, I can guarantee you're not going to have any sensitivity If you just follow it improperly. The first one is for Regene Universal. Now we're going to apply velvet etch to the cavity for 15 to 20 seconds. If it goes a little longer it won't matter, it's just fine. And then you're going to rinse this away and then you're going to dry it. But when you rinse it you can just. The velvet etch is so nice, it has such a nice viscosity, but it's so light that it can be rinsed away with just a water stream by itself. It does not have to be rinsed with an air water spray which tends to be messy and get all the little place. You really don't have to do that. Just the water stream alone for five seconds will get this velvet etch off. And then when you you'll have a chance to look at it, when you're rinsed it and dry it, you'll see exactly what that looks like and see if you agree with what I just said but I believe you will.
Speaker 1:Then I would recommend a coat of Desensimax, which is the desensitizer that this apex provides, and it has the ability to shut down MMPs or matrix and metalloproteinases. It shuts down all the bad stuff that can happen to bonds. If you're into that, we put on a coat using a very small micro applicator, put it all over the cavity preparation, leave it wet and then you apply three brush holes of the region universal. It's going to look thick, but don't worry about that. Bring the high volume suction near the cavity prep and then dry it gently at first, so you just don't blow everything out of the cavity. Dry it at first gently and then bring the iris range close and dry it thoroughly. You're going to see it thins out very, very rapidly and then, once you've got that dried off, then, like your 10 seconds if you're using the turbo version of, say, something like Pink Wave in its turbo, you can do it in three seconds. That would be just fine.
Speaker 1:Then you want to apply a layer of the regen flow, the bioactive flowable, to all of the dentin and the CAVO surface margins. So bring it right up to the mark because that's where you need it. This is where it's really really important. Cover all of the pulpal floor, bring it to the CAVO surface margin and bring it up the axial walls. You don't want it to be on the load bearing surfaces, but you want to bring it up the axial walls a bit because it's going to provide protection there as well, and then you can light activate this. Either it can be 20 seconds of a standard mode. If you're using the turbo mode you can do it two cycles of three seconds apiece. Now Titan would polymerize in less time than this does. It polymerizes very, very quickly, but the addition of the bioactive fillers to the material makes them more opaque and requires a bit more energy to light activate. So again, either 20 seconds in a standard mode or two cycles of three seconds in a turbo mode will do it, and then you can add the exquisite composite and that incrementally in each layer should be light activated. Either 10 seconds or so in a standard mode. It can be about three seconds at least initially in the turbo mode and then finish as you normally would.
Speaker 1:Now, for the region self-etch it's not a lot different, because you're going to find that no matter what you do, there's always going to be about three bottles or three steps, three things you have to do. Doesn't matter what it is, they all have similar kinds of steps that you have to condition the denonamely got a primary going to bond it. I mean, that's state that goes for everything. So what we do, we start with a dry prep. You want to make sure when you're using region self-etch, which again is the bioactive version of surpass, dry the preparation thoroughly. You apply the region SE bottle, one which is like surpass one, agitate this for 10 or 15 seconds. You leave it wet, just as you would surpass. You have three coats of region bottle, the region SE bottle to, just like you would have applied the surpass to three coats of that. And then you dry this thoroughly. So now, after the application of bottle to we dry it very, very thoroughly. The more you dry it, the better it will get. So you apply a coat of region SE bottle three, which was surpass three, but in the bioactive version, and then air thinness, as much or as little as you wish. I mean, generally speaking, you want to have a thinner adhesive layer. So you go ahead. You know, my office we always within the sound as much as possible. And then this is light activated again, 10 seconds in a standard mode or three seconds in the pink wave. That it's turbo mode. It requires a little bit less time, but just give an equal amount of energy. And then you again apply the region flow, just as we described before, one or two millimeters to the cave, to all of the prep, all the purple floor, cable, surface margins, taking up the axial walls, and then you light activate that for either two cycles of three seconds in the turbo or 20 seconds in a standard mode, and then the composite also is introduced and incrementally placed and might activate it. If you have a smaller cavity that's not under, not a high C factor, you can, you can bulk fill it and let it go to that.
Speaker 1:That's for another, another webinar, as it were, and what I'm going to do is present you a clinical example of doing what we just talked about. You can see the carries through here. We're going to evacuate that, we're going to stain it. We have the care, the same, from this, the beginning, again, the red and green stains that are available to us. We're going to make sure that all of the carries is used in the green and make sure that all of the carries is eliminated, certainly from anywhere near the margins. As you get deeper, if it gets really really deep, you may find that you might want to just leave a little bit of stuff in there rather than risking exposure. But again, that's for a separate discussion.
Speaker 1:Now we're going to put into this the a matrix, whatever matrix you can make fit. There are a number of different kinds. You have, you know, all these cervical, these matrices are available to you have. There are a number of them that serve very, very well. This is just one of them. So place this matrix in place and we're using these, these v3 rings, which I'm very, very fond of I think that's very, very important the wedge we place the wedge in and then drop the v3 ring on this and make and just assure yourself that, two things that make sure you can take some sort of instrument, make sure you're in contact with the Jason tooth and then make sure you have a real good fit right here along the ginger margin. So now we're going to use region universal, which requires my opinion.
Speaker 1:I this is the way I use a phosphoric acid Etchant. So phosphoric acid etchant goes in here between, say, around 15 seconds, maybe 20 seconds, and then we're going to rinse this and if you're using the velvet edge, you can just use a five second water stream, but this is before velvet edge, and now we rinse it and we dry it. You can see very clearly that there is a very good and adequate more than adequate etching of enamel and dentin. Not worried about that. So now what we're going to do is introduce the sense max. This is the desensitizer, which contains all kinds of goodies in it Chlorhexidine is in it, fluoride is in it, all kinds of cool stuff is in there and an M and MMP killer is in there as well.
Speaker 1:So we take a small applicator, like this little tiny micro applicators, and we put apply this to the entire preparation. This stays wet, leave this wet in place. Then we apply. Three we shake the bottom. You should both, both with region universal and the region SE region self etch model. Number two should always shake these bottles before you use them, just to make sure that the material is properly distributed. Three we put out some. Put the strip out of dropper to material in a well. Apply three brush rolls to the cavity preparation. You can see what it looks like. It looks more of a lemak here actually is going to end up being, but don't worry about that. Now we start to dry this gently at first and then thoroughly, and then you can see it. All the liquids are gone and that's what you're looking for. The liquids have been evaporated and we have a nice dry surface now and this is why it activated for again, either five seconds or 10 seconds, dependent. Three seconds or 10 seconds, depending on what you're doing.
Speaker 1:But I'm going to introduce one other little variable back here in here, and that is previously if you're, if you're going to place initially a very thin layer of the region flow, the bioactive material, you can place a very thin layer about this, about a millimeter or a little bit, more or less or so, and you can light activate both the adhesive and the flowable together. And now again would require this, the two cycles, six seconds apiece, or 20 seconds with a standard mode. But you can actually do that and you know I've been something I've been doing for about 1314, 15 years something on that I gotta be 15 years and it was very successfully. As long as you keep the full layer, the initial flow of the layer, thinner and you make sure you get energy to it, you can do that. And then so this is why it activated again to three second cycles on boost or 10 seconds and standard. And then, once you have that in place and you know I'm not hesitant, I'm not reluctant to add a second layer of flowable, making sure that I want to get where I want to be in its, along the cable surface margins, but not at the occlusal surface.
Speaker 1:Then we add incrementally the exquisite composite here and then light activate that at first build the proximal wall. Is that I? That's what I'd like to do, is do the proximal wall first. This is light activated and then we'll add the smaller portions to it. Once these are added in, you could do something called pulse activation. Sometimes when they have these higher C factor resting restoration of county preparations, when I place composite in them I might take the light initially and just turn it down especially if it's higher power light just for about a second, second and a half and turn it off. And so that was pulse activations, the concept that created back in 1994, 95 and wrote about it published in 1996. And what that does is adds a packet of energy to these composites that doesn't force them to polymerize too fast, and then we can go back and let activate them more later.
Speaker 1:Once we get the composite placed will remove the matrix, the ring and the wedge and then we're going to shape this down. Now everything else becomes fairly simple. We'll dis the margin here just to hit to create a marginal ridge, and then we'll adjust the occlusion, make a back, adjust the occlusion as is indicated and you can see we have a very nice restoration. You know any defects along that margin and so completed restoration, this, doing it this way, will assure you that you do not have any sensitivity. You'll have a very durable restoration.
Speaker 1:One of the other things I started thinking about is where else can we, where do we need things like resistance to asset attack and where can we look? You know, hope to get regeneration, and so we've got a lot of restoration of teeth and it's these yellow, you know, these partially demineralized restorations on teeth. You know we could kind of clean this out using clean and boost just to get the junk out of, get the in organics and everything out of there, and so you can put a pit fisher seal in here. You can even put the region, just a thin layer region flow in here, kind of just kind of rub it into that kind of something. We're similar to what people were talking about when they talked about acid etching, you know, partially demineralized areas and introducing resonance to it. Yeah, I thought about that and that's okay, but it's when you can do it with a bioactive material, that's phenomenal.
Speaker 1:And so this is one of the things we have been doing is into these areas, into these kinds of lesions, and especially in the kids. You know who, despite your best efforts, don't clean these things the way they should and they've been. Hygiene isn't that hot, but at least you can give them a little bit more of a fighting chance by cleaning these out, you know, getting like a clean boost and then smearing some of this stuff in into here where there's a pit, fisher seal or it's the flog material, rub it in and then, you know, then might activate it. You're at least giving them a fighting chance to do something over here. So this excites me greatly and what I hope to see and I so far I'm seeing a very nice result of this is that there's no, none of this degradation of. You know, every time you cut out an old restoration on, or even doing a chrome prep, we look at Jason, old resident composite and you see these defects along the margins, the cervical margins, and what I'm really hoping for is that this will be minimized, if not prevented entirely, because you know we're what we have is a product that can resist the attachment of bacteria and actually kind of help destroy bacteria that try to attach in these areas. So this is this is the kind of stuff we're really hoping for and again, if you have it in a saying that your restoration that you placed in the tooth and you have that bioactive material kind of creeping up over here. It can come into contact with an adjacent tooth and I'm looking for the ability to afford it to help protect the adjacent tooth from demonization as well, just by contact alone. So again, something else I've the promise is here is really really sky high.
Speaker 1:Now just a few other things to mention while we're on. This is the velvet edge, this thing. I fall in love with this. This is a wonderful edge. It applies very easily, it stays where you put it and, as I mentioned, it does rinse off with just a water stream in five seconds. Some of the takes. Now that may upset some of my friends over at Vista Apex, but that's my experience with it and I would say just try that and see what you think. You know you can always rinse it more, but this is just such a great product. And then we have a killer of a Zirconia primer in. You know, zrp, this is something again reformulated. Finally, I finally cracked the code on this. This provides you, when you use this as directed, the highest immediate bond strength to Zirconia you're going to ever see. I mean that it's just a great product. And then we have the pink wave which I've been talking about.
Speaker 1:This is a really, really neat light. It has a built-in trans-illuminator in it. There's three curing modes there's boost, there's standard and ramp Ramp. I'm not that crazy about ramp, but ramp is a 20 second cycle and you can use it and that's fine. I like the discontinuous kind of energy insertion myself, but it's about a 1500 milliwatts per square centimeter in the standard mode and about 1700, a little over 1700 in the boost mode. But you got it is a very nice thing. It has a large lens on it and it columnates the light very, very well and it's a terrific, terrific tool to have. And you can see the little dial, little buttons here that you can see the difference. You can know what mode you're in. You can change the mode here.
Speaker 1:And this is the igniter, right here, the activator, I should say so. I mean it has a lot of advantages. You can cure anything from 375, which is sort of into the ultraviolet range. So if you have things like phosphine oxides, you're going to be able to activate those. Phosphine oxide initiators are found in clear composites, the ones that say they're clear, they don't change color in their star. That's where you really have your low and lower wavelength photo initiators. And then blue is mostly a camera chrono, but it cures all. A light, activates all of these materials and because there's an IR, there is an infrared output with this as well, if you are. The one thing that's good about the standard mode, the ramp mode, is that you'll have an IR accompanying the light. That's activating the composite and the infrared actually does reduce the amount of polymerization, shrinkage and, more importantly, shrinkage stress that occurs around these materials. So there's a lot of growth out in this particular material, this sling.
Speaker 1:Then I want to call your attention to the fact that this is really well rated by CR over here. They actually measured this out the irradiance of 3 millimeters at close to 2000 milliwatts, which I find that interesting when the assertion from this is that it's around 1700, but they've measured it out at almost 2000, which is okay with me because we're going to keep that pretty restricted to about three seconds. But if you look at the size of the heads, then this is kind of important. And you see, I'm not a big fan of anything. When you start to see these, you know fiber optic tubes. I don't like this. I got away from that a long time ago. And these other ones are small and this one I don't care for either. But these are smaller lenses. This is a very large lens and it collimates. When you look at spot uniformity, the collimation, they rated this as excellent or good Overall. It's a pretty nice rating for this right here.
Speaker 1:But here and then there's one other thing I want to show you the laser. The laser 4000 milliwatts per square centimeter Now that's pretty potent, that's getting pretty potent. At that point I studied a laser about oh golly, probably close to 30 years ago. I actually got a laser. A manufacturer sent me a laser and we actually put it on, put it in restorations and light activated and it was at the proper wavelength and everything else. You see, the collimation as measured by CR was just fair. The spot uniformity is just fair, and that's with the laser. I find that thing that's kind of interesting. But anyway, when I put class one composites in and light activated them with the laser that I had, I saw something I'd never seen before and have never seen since, and that is not only did it crack the composite, the polymerization shrinkage was so severe that it cracked the composite and then actually cracked the tooth right through here, as you can see, cracked the tooth Because that's that bothered me. So I've never since then I've not been a fan of laser polymerization of resin composites, and so when I saw the claims, I heard this I actually did hear this from a notable lecturer saying you could cure composite from across the room, and I could never figure out exactly when I was going to do that, but anyway. So now we have two other things I want to talk about quickly.
Speaker 1:Desensimax is kind of the ultimate desensitizer. You can use this on all kinds of surfaces that are just sensitive. You put this underneath whatever you're, you're bonding and you're just not going to have any sensitivity. It's going to be gone. It's that simple. But this is for placement of direct restorations and this is what I dress on all crown preparations that leave the office. Just before I put the temporary on, we soak them in this and let it sit for a few seconds dry and maybe throw in another coat on, and that is what we use to treat crown preparations, particularly in I mean in vital teeth.
Speaker 1:Now, this is for the use of time of preparation, but the desensitizer in here works will work adversely against a glass anomer or I mean a resin modified glass anomer. Resin modified glass anomer and glass anomer is in zinc, phosphate and everything else adheres to teeth by self etching. That's how they all work and if you add a desensitizer prior to that, you will reduce the effectiveness of the resin, of the cements ability to self etch and stick to the tooth. So I would not use this. On the date of delivery On date of delivery, what we use is this bond saver. Bond saver has all the same ingredients in here, except without the desensitizing element. So bond saver is a good thing to have in crown preparer or crown deliveries because again, it has an MMP killer, it has chlorhexidine, it has fluoride and it has all kinds of stuff in it. So it's got all the stuff in there except for the desensitizer. But if you use this you'll find you're not going to have a lot of sensitivity on delivery of the crown anyway. So these are two really good products to look at.
Speaker 1:Seem free is our wedding resin and lubricant sculpting resin, if you will. It is a non light curing resin. In other words, you can use this to putty around materials and push them around, but it will not light cure. So if you have a little bit of excess around the cavity on top of your composite, it is not going to light cure. When the composite light cures, once this is covered by a composite, it will co polymerize instantly with that composite, but it will not light cure on its own and that makes it great. So you're not getting layers of unfilled resin along your margins or between layers of composite. Works out great for that.
Speaker 1:Clean and boost is kind of a Swiss army knife of cleaning products. I really get a kick out of this thing. I can grab this. You want to remove celebrate pellicles? You want to remove them from teeth? You can use this just for a few seconds on it or clean them up Instead of using particle abrasion like some people like to use. This will do the job with that very, very nicely. Get rid of it, and if I'll pick this up, you're going to sound funny, but I got somebody a lot of plaque all over the place. I'll pick this up and I'll use this to wipe out plaque, because this will do. It's got something that takes both inorganics and organics out as well. That's what I do with it. Besides, that's kind of an off-label use, but that's what I do. But it's a great material to clean up cavity preparations, crown preparation, all kinds of stuff.
Speaker 1:Now, as we said, bioactivity and dentistry is really eliciting a specific biologic effect and it has to happen in vivo. That's what bioactivity is about. The difference between in vivo and in vitro there are two parts of it. You can initiate it on an in vitro level. It's an inorganic side, but the organic side, the rest of the repair of defects and stuff is definitely an in vivo state and that's what you're hoping for.
Speaker 1:The materials that we've had in here represent a sea change in dentistry. I mean, I think the promise of these materials is immense. What we can possibly do to make products make things better gives us the ability perhaps to heal defects, to repair teeth and make just overall better restorations. So you have more confidence in restorations, reliability, predictability and better outcomes. That's what in the bottom line is that we have better outcomes to all of this and that's what we're all after.
Speaker 1:So the bottom line again, no matter what we're doing, I'm after one thing and that is performance. I want to place restorations that last a very long time, that I can feel comfortable with, knowing that I place them and I know they're going to go on and survive a long period of time and provide a great service to the patients that I place them in. And that's kind of what this is all about. And, as I did before one of my joint, one of our get-togethers, I have a couple of words of wisdom from a noted philosopher by the name of Dean Martin, who said that good judgment comes from experience and experience, well, that comes from poor judgment. And with that I bid you good night.
.png)