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Dental Tribune Middle East & Africa Edition | 3/2016 11 mCME mCMESELFINSTRUCTIONPROGRAM CAPPmea together with Dental Tribune provides the opportunity with its mCME - Self Instruction Program a quick and simple way to meet your continuingeducationneeds.mCMEoffersyoutheflexibilitytoworkatyour own pace through the material from any location at any time. The content is international, drawn from the upper echelon of dental medicine, but also presentsaregionaloutlookintermsofperspectiveandsubjectmatter. Membership YearlymembershipsubscriptionformCME:900AED OneTimearticlenewspapersubscription:250AEDperissue.Afterthe payment,youwillreceiveyourmembershipnumberandallowingyouto starttheprogram. 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Formoreinformationpleasecontactevents@cappmea.comor +97143616174 FORINTERACTIONWITHTHEAUTHORSFINDTHECONTACTDETAILSAT THEENDOFEACHARTICLE. bonding agent because the bonding agent is essentially the RMGIC. The RMGIC acts as the interface between the GIC and the com-posite mate- rial. It combines the GIC, RMGIC and compositeinawaytoformwhatcan best be described as a “monolithic biomimeticrestoration.” This restoration is an “open sand- wich” type of sandwich technique. That is, the GIC component is ex- posed to the oral environment (Fig. 13) at the gingival portion of the res- toration. It is quickly and efficiently accomplished and has significantly reduced postoperative sensitiv- ity compared with typical direct RBC techniques.Ihavebeenplacingthese types of direct posterior restorations since 2008. They have become the cornerstoneofmypractice. Techniqueprocedure(Fig.14) After placement of an appropriate dental matrix, the technique incor- porates the use of 37 percent phos- phoric acid to prepare the tooth for restoration. The acid is essentially “flooded” into the preparation in a similar manner to doing a “total- etch” RBC. It is, however, washed off afterfivesecondsofplacement. The tooth is then dried but not des- iccated. The area remains slightly moist because the GIC that will be placednextishydrophilic. Fill the preparation with the tritu- rated GIC material up to the level of the DEJ, then immediately place the triturated RMGIC in a very thin layer to cover the GIC and walls of the preparation. Finally, place the com- posite over the previous materials to slightly overfill the preparation. With a large round burnisher dipped in an unfilled resin material (i.e., Riva Coat by SDI or G-Coat by GC), wipe away the excess GIC and composite restoration material to create your margins and prevent ditching and whitelines. The occlusal table of the restoration can then be compressed gently with a plastic occlusal matrix by either having the patient bite or by the operator pressing gently with his thumb or forefinger to improve the coalescence of the three materials. This can help reduce the time in- volvedincreatingthefinalocclusion of the restoration by creating a func- tionalocclusaltable. The restoration is then cured for 30 to 40 seconds with an LED curing light that generates at least 1,500 mw/cm2 . Appropriate light output is critical for all direct cured restora- tions, and assurance that appropri- ate output is provided by the curing light is needed for complete cure of anydirectrestoration. Therestorationisevaluatedforcom- plete cure and then a layer of an un- filled resin is placed on the exposed GIC/RMGIC/composite complex and cured for an additional 10 sec- onds. The matrix band is removed and the restoration is trimmed and polished as any typical RBC restora- tionwouldbe. I have found that an entire three- surface posterior restoration can be accomplished in less then three minutes once the matrix has been placed. Typically, finishing the res- torationcanalsobedoneinlessthen three minutes. This makes the direct posterior restoration quite efficient and beneficial to the clinician and thepatientbecauseweareproviding a restoration that will help enhance healing of the dentition and reduce recurrent decay and restorative fail- ure. Nanotechnology in dental materials Nanotechnology involves the pro- duction of functional materials and structures in the range of 0.1 o 100 nanometers by various physical or chemical methods. Today, the de- velopment of nanotechnology has becomeoneofthemosthighlyener- gized disciplines in science and tech- nology because it can stimulate the creationofmanynewmaterialswith previously unimagined applications andproperties. Several studies17,18 have shown that the inclusion of these types of nano- fillersandnano-fibersintothedental materials (dental composites and bonding agents) can improve the physicalpropertiesbyincreasingthe strength, polishability, wear resist- ance,estheticsandbondstrengthsin manydentalapplications. It is also envisioned that the incor- poration and utilization of these na- noparticles in the form of nanorods, nanofibers, nanospheres, nanotubes and ormocers (organically modified ceramics) into dental restorative and bonding agents can create more bio- mimetic (life-like) restorations. This will not only enable these materials to mimic the physical characteristics ofthetoothstructure,butwillalsobe abletofacilitatetheremineralization ofthatstructure. As Saunders states in his conclusion, “such nanorestorative biomaterials couldverycrediblybethenexttrans- formativeclinicalleap”inrestorative dentistry. Giomers In that vein, an exciting advance- ment in bioactive materials is the development of giomer products (Shofu Dental, Beautifil II, and Beau- tifilFlowPlus). These giomers are resin-based com- positesthatcontainpre-reactedglass ionomerparticles(S-PRG). These particles are made of fluoro- silicate glass reacted with polyacrylic acid(justlikeaGIC),justbeforebeing incorporated into the resin. This cre- atesanewtypeofbioactivematerial. Thesegiomerproductsdisplayprop- erties in a manner similar to GICs19: They release ions and recharge with ions from the oral cavity, inhibit plaqueformationandneutralizeand buffertheacidsofthemouth.20 Noothercompositematerialhasthis property to date. I use these giomers instead of traditional nano-hybrid composites in my restorations because of these properties. They complete the entire biomimetic and bioactive nature of all the co-cure proceduresthatIcreate. The Beautifil Flow Plus product line has also expanded the way that I cre- ate restorations due to their unique viscosities. These materials can be stacked(Fig.15)andusedinarestora- tive process I call the “modified resin conetechnique”(Fig.16). They can also be applied to create direct composite veneers that can be easily placed, sculpted and highly polished (Fig 17). Easy placement, the ability to stack and maintain position and shape, plus their bioac- tive nature, make these materials a “gamechanger.” Resin-modified, light-cured bondingagents Another advancement that I have been working with is a product that isaresin-modified,light-curedbond- ing agent (SDI, North America: Riva Bond LC). This product is a specially formulated liquid RMGIC that can be used to bond composite restora- tions in the traditional sense, used in traditional sandwich and modified sandwich techniques and, of course, used in the Co-Cure Technique. This concept is especially appealing in light of the research that indicates RMGICs provide quite good margin- al seal when used as a bonding agent on cut dentin surfaces.14 I especially like to use it with the Co-Cure Tech- nique and when doing anterior res- torations. Using this technique I am able to get a completely biomimetic, bioactive restoration in both situa- tions because of the bioactive nature ofthematerialsused. The technique for use of this RMGIC bonding agent with composite is as follows: 1) Etch with 37 percent phosphoric acidforfiveseconds. 2)Washanddrybutdonotdesiccate. 3) Triturate and apply the RMGIC bonding agent with a micro-brush andcurefor20seconds. 4)Placecompositetofilltheprepara- tionandcureasappropriate. When I use this material in the Co- Cure Technique, I just substitute it for the traditional RMGIC material thatIwouldhaveusedotherwise. Resin-modified calcium sili- cates Another recent interesting product release is from Bisco and is called TheraCal™ LC. This light-cured bio- active material is used to seal and protect the dentin-pulp complex. It is the first of a new class of internal pulpal protectant materials known as resinmodified calcium silicates (RMCS). It acts as a pulp capping and liner material. Calcium hydroxide (CH) hasbeenthe“gold”standardforpulp capping for many years. However, it hasalwayshaddifficultiesinuseasa linerunderRBCadhesives. Infact,despitetheirfrequentuse,the success of CH based therapies is only 30to50percent.21 It has also been shown that tradi- tional resinbased light-cured liners have been cytotoxic to cultured od- ontoblast-like cells, while light-cured resinbased MTA cements presented the lowest cytopathic effects.22 Based on this, the creation of light-cured RMCSisalogicalstepindevelopinga solutionfordirectpulpalprotection. Calcium has been shown to be cru- cial to the formation of apatite, den- tin bridge formation and re-apatite potential of affected dentin. Addi- tionally, alkalinity also seems to be contributory toward this goal. This combination in the RMCS material appearstoformgood,hardandthick dentin bridges and stimulates den- tin pulp cells to turn into odotoblas- ticdentincells.23 This type of material represents a promising new direction in direct pulp-capping clinical procedures with its ability to form apatite and further contribute to the formation ofnewdentin. ◊Page10 Fig.13 Fig.14 Fig.15 Fig.17 Fig.16 Conclusion It is my belief that using bioactive materials in the provision of care for my patients has been paramount to the success of the care I have been providing. In this way, I have pro- vided ways to heal the dentition, en- hance the restoration and improve thehealthofmypatients. I believe we are on the threshold of further bioactive material advance- ments and that learning and incor- porating these restorative materials into the day-to-day provision of care will continue to help our patients, ourpracticesandourprofession. References 1. J. De Munck, K. Van Landuyt, M. Peumans, A. Poitevin, P Lambrechts, M. Braem, and B. Van Meerbeek. A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods and Results. J. Dent Res 84(2):118–132, 2005. 2.C.M.Amaral,DDS,MS,PhD;A.K.B. Bedran-Russo, DDS, MS, PhD; L. A. F. Pimenta, DDS, MS, PhD; M. S. Shino- hara, DDS, MS; M. C. G. Erhardt, DDS, MS, PhD. Effect of long-term water storage on etch-and-rinse and self- etching resin-dentin bond strengths. General Dentistry, May–June 2008 , Volume56,Issue4,pp.372–377. 3. Tay, Carvalho, & Pashley: Water movement across bonded dentin — too much of a good thing? J. Appl. OralSci.vol.12,no.speBauru2004. The full list of references is availlable fromthepublisher. John C. Comisi, DDS, MAGD, has been in private practice in Ithaca, N.Y., since 1983. He is a graduate of Northwestern University Dental School and received his Bachelor of Sci- ence in biology at Fordham University. He is a member of the American Dental Association and its tripartite organiza- tions, the Academy of General Dentistry, the American Equilibration Society, the International and American Association of Dental Research, a research associate at New York University Dental School and an editorial board member of Den- tal Products Shopper Magazine. Comisi is a Master of the Academy of General Dentistry, and holds fellowships in the Academy of Dentistry International, the American College of Dentistry, the Pierre Fauchard Academy and the International CollegeofDentistry.Hemaybecontacted at jcomisi@jcomisi.com. Dental Tribune Middle East & Africa Edition | 3/201611