Endo Tribune Middle East & Africa No. 5, 2019
Novel applications of a bioactive resin in perforations, root resorption and endodontic-periodontic lesions
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DTMEA_No.5. Vol.9_ET.indd
NL
Y
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LS
NA
IO
SS
FE
O
PR
NT
AL
DE
www.dental-tribune.me
Published in Dubai
September-October 2019 | No. 5, Vol. 9
Novel applications of a bioactive resin
in perforations, root resorption and
endodontic-periodontic lesions
By Dr Marta Maciak, Poland
During the last decade, a considerable amount of attention has been
directed towards the development
of so-called bioactive materials. To
understand this phenomenon better and to avoid misinterpretation,
a condensed review of the literature
and an assessment of various definitions need to be considered.
There are already several commercially available dental materials
that can be defined as bioactive. For
instance, any fluoride-releasing material, calcium silicate- and calcium
aluminate-based cements, and calcium-based or calcium-containing
materials. Biomaterial scientists
in the field of implantology have
adopted the word “bioactive” to
mean materials that are bound to
each other through a biomineralised
interface. There appears to be confusion within the dental profession, including among scientists, clinicians
and industry persons, to what extent
biomineralisation can be achieved
with dental materials and which ma-
terials can be appropriately termed
“bioactive” or “biomineralising”.1
Bioactivity has been defined and
can be interpreted in various ways.
A broad definition that has several
meanings is the following: a material
that is able to have a biological effect or a material that is biologically
active and forms a bond between
the tissue and the material.2 In the
field of tissue engineering, the term
“bioactivity” is related to the cellular effects induced by the release of
biologically active substances and
ions from the biomaterial, for example from bioactive glasses both
in soft- and hard- tissue engineering
applications.3, 4 In addition, its activity has been demonstrated in pulp
capping experiments in non-human
primates.5
Thus, in medicine, bioactivity covers all interaction of materials with
living cells and tissue, including the
effects of pharmaceuticals. In biomaterial science, with bioceramics
and bioactive glasses, bioactivity of
a material usually denotes that the
material is capable of forming hydroxyapatite minerals on its surface
in vitro and in vivo.6
The following theoretical question
should be asked: can a material that
releases ions for biomineralisation
be considered bioactive or is the
substrate on which the biomineralisation occurs bioactive? Thus, bioactivity of dental materials relates to
their potential to induce specific and
ÿPage A2
AD
EXPAND
YOUR
MIND
ADAPTIVE. EASY. SAFE. EFFICIENT.
www.fkg.ch/xpendo
[2] =>
DTMEA_No.5. Vol.9_ET.indd
A2
ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 5/2019
◊Page A1
ACTIVA BioACTIVE-RESTORATIVE
and ACTIVA BioACTIVE-BASE/LINER
in lieu of mineral trioxide aggregate
(MTA) and Biodentine (Septodont)
for selected endodontic and other
procedures.
Fig. 1
The cases presented here are offlabel treatments using ACTIVA BioACTIVE-BASE/LINER in cases with
a poor prognosis and in which extraction (and an implant) may have
seemed a more obvious choice of
therapy. These procedures are not
listed in the company’s indications
for use and were carried out by the
author after explaining the possible
potential benefits, as well as the risks
to the patient. All of the patients
agreed to the treatment and signed
an informed consent form for endodontic treatment.
Fig. 2
Case 1
Fig. 3
A 28-year-old female patient was
referred and presented with pain of
tooth #46. The referral letter stated
that endodontic retreatment was
needed and the perforation had been
closed with MTA. The patient was in
considerable pain when eating and
when closing her mouth. Her medical history did not present any contraindications to dental treatment.
Fig. 4
Fig. 5
The clinical examination showed a
temporary filling in tooth #46. A radiograph taken on 20 October 2015
showed extrusion of MTA into the
furcation, as well as a bony defect
(Fig. 1). Perforation of the floor of the
pulp chamber was diagnosed.
Fig. 6
Fig. 7
Upon removal of the temporary
filling, a large amount of purulent
exudate filled the pulp chamber and
was evacuated. After the MTA had
been removed, the furcation was
flushed with metronidazole (liquid;
Polpharma) and 2% chlorhexidine
(Cerkamed). The borders of the perforation were refreshed with a carbide
bur, and then the pulp chamber was
etched with 37% orthophosphoric
acid for 10 seconds, followed by a
thorough rinse. Through the perforation, a collagen sponge (ANTEMA,
Molteni Dental) was applied to support the ACTIVA Bio-ACTIVE-BASE/
LINER and to protect the underlying bone defect. The sponge was not
visible on the radiograph. The canal
orifices were protected with cotton
pellets and the entire pulp chamber
was treated with a dentine bonding
agent (DenTASTIC UNO, Pulpdent),
which was light-cured, and then covered with ACTIVA BioACTIVE-BASE/
LINER, covering the floor of the pulp
chamber (Fig. 2).
Fig. 8
Fig. 9
Fig. 10
The tooth was closed with GIZ glass
ionomer (Ihde Dental) as a temporary filling. The patient was painfree within two days. A follow-up radiograph taken on 3 November 2015
(14 days postoperatively) showed the
beginning of the healing of the bone
in the furcation area (Fig. 3).
Case 2
Fig. 11
Fig. 12
intentional mineral attachment to
the dentine substrate.7
Another definition has been presented in an article by Lööf et al.:
“Bioactivity of a ceramic material is
a surface property that provides a
bond between the material and living tissues without fibrous encapsulation.”8 In yet another definition,
bioactivity is described as follows: “A
bioactive material is one that forms
a surface layer of an apatite-like material in the presence of an inorganic
phosphate solution.”9
ACTIVA
BioACTIVE-RESTORATIVE
and ACTIVA BioACTIVE-BASE/LINER
(Pulpdent) have been shown to exhibit bioactive properties based on
this last definition. ACTIVA BioACTIVE products are the first dental
resins with a bioactive ionic resin
matrix. They have a shock-absorbing
rubberised resin component and
reactive ionomer glass fillers that
mimic the physical and chemical
properties of natural teeth. These bioactive materials actively participate
in the cycles of ion exchange that
regulate the natural chemistry of the
teeth and saliva and contribute to the
maintenance of tooth structure and
oral health. ACTIVA has the strength,
aesthetics and physical properties of
resin composites and is more bioactive than glass ionomer cements.10
ACTIVA seals teeth against mi croleakage11, 12 and its continuous release
and recharge of significant amounts
of calcium, phosphate and fluoride
ions provide patients with long-term
benefits.
In the US, the bioactivity claim for
ACTIVA, being the first bioactive
resin material, has been accepted.
Based on its strength and durability
due to a patented rubberised resin
molecule that absorbs stress and
resists fracture, the author has used
A 16-year-old patient was referred
with root resorption of tooth #21. A
CBCT scan and radiograph (Figs. 4
& 5) taken on 30 March 2017 clearly
demonstrated the root resorption.
Note the temporary filling in the
pulp chamber. The patient’s medical
history was non-contributory. The
diagnosis was mixed internal and
external root resorption.
After removal of the temporary filling, inflamed granulation tissue was
seen inside the canal. In spite of the
fact that the apical portion of the canal was calcified, it was located. The
canal was shaped and cleaned with
the Self-Adjusting File (SAF) System
(ReDent NOVA) and XP-endo Finisher (FKG Dentaire), and flushed with
5.25 % sodium hypochlorite (NaClO),
17% EDTA (Cerkamed) and metronidazole (Polpharma). As a first temporary canal filing, Dexadent (Chema-Elektromet) was applied for one
week to treat the inflammatory tissue in the canal. During subsequent
visits, the canal was rinsed with
40% citric acid (Cerkamed) and 2 %
chlorhexidine (Cerkamed) using the
SAF System and XP-endo Finisher. A
temporary filling of Multi-Cal (Pulpdent) mixed with 2% chlorhexidine
(liquid) was inserted into the canal.
Initially, the temporary dressing was
replaced every two weeks to accomplish removal of granulation tissue
and to stimulate bone regeneration. Over the course of about seven
months, a reduction of the bone lesion was observed, as evidenced by
radiographs (Fig. 6) and CBCT and
under high mag- nification.
The final treatment after approximately 11 months (Fig. 7) consisted of
cleaning the canal with the XP-endo
Finisher and EDTA and 2% chlorhexidine irrigation. The resorption area
was plugged with a collagen sponge
(Antema) to provide support for
ACTIVA BioACTIVE CEMENT and to
prevent it from flowing beyond the
root structure. A dentine bonding
agent (All-Bond Universal, Bisco) was
applied to the canal space, but not
polymerised, just slightly air-dried,
and the root was filled from the apex
to the pulp chamber with ACTIVA
BioACTIVE-BASE/ LINER. A fibre post
(Cytec blanco, Hahnenkratt) was immediately placed, following which
the pulp chamber was filled with ACTIVA. After 20 seconds, the restoration was light-cured from three different directions for 20 seconds each.
The final result can be seen on a radiograph from 13 February 2018.
Complete bone healing adjacent to
the resorption area was observed
(Fig. 8). While the radiograph shows
the fibre post, the collagen sponge
and ACTIVA BioACTIVE CEMENT do
not possess sufficient radiopacity to
be seen on a radiograph.
Case 3
A 63-year-old female patient presented for dental treatment. A panoramic radiograph (Fig. 9) revealed
a heavily restored dentition with
single crowns, a three-unit bridge
and multiple missing teeth in both
arches. She complained of pain in
the mandibular right premolar area.
Her medical history did not present
any contra-indications to dental
treatment.
When the patient was informed
that tooth #45 would have to be
extracted, she objected and asked
if anything could be done to save it,
even if only on a temporary basis, as
she was reluctant to commit to wearing a removable partial denture. She
thus consented to a treatment that
offered no guarantee of success.
Clinical examination showed thirdstage luxation and pus in the gingival pocket. A radiograph showed
a three-wall infrabony pocket (Fig.
10A) reaching the apex of the root.
The diagnosis was periapical periodontitis with purulent exudate and
root caries on the mesial aspect. The
treatment consisted of endodontic
and periodontal treatment after a
panoramic radiograph and realtime
polymerase chain reaction (PET test,
PET Plus, MIP Pharma) were performed.
Endodontic treatment was performed on 2 July 2014 with a HyFlex
file of size 25.04 (COLTENE) and the
SAF System. The pus was evacuated
from the root canal and the canal was
flushed with 5.25% NaClO and met-
ÿPage A3
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DTMEA_No.5. Vol.9_ET.indd
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ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 5/2019
◊Page A2
ronidazole, and Dexadent ointment
was applied and left for one week. To
avoid extra expenses, no bone grafting material was used; only a deep
curettage was performed.
An occlusal cavity was prepared
and filled with ACTIVA BioACTIVERESTORATIVE, and the tooth was
splinted to the adjacent premolar
with fibreglass and ACTIVA (Fig.
10B). The purpose of the splint was
to lend support to the tooth, which
presented with a Class III mobility,
thus promoting healing. After a few
days, the patient reported being free
of pain, and no exudate in the canal
was observed.
period of two weeks. Two weeks later,
the Multi-Cal was removed with the
SAF System using 40 % citric acid
and distilled water. Then the canal
was rinsed with 2% chlorhexidine
and dried with suction. GuttaFlow
(COLTENE) was used as a sealer, and
a master cone was softened in chloroform and placed in the canal. Vertical hot condensation was carried out
in the apical part. The remainder of
the root canal was filled with a continuous wave of gutta-percha. The
period until the next appointment
determined whether the treatment
would be successful or not. Healing
of the infrabony lesion continued
during this period (Fig. 11).
On 10 July 2014, the canal dressing
was changed to Multi-Cal mixed
with 2% chlorhexidine and left for a
Three months later, the gutta-percha
was partially removed from the canal, which was etched and rinsed, fol-
lowed by application of the dentine
bonding agent (All-Bond Universal).
The canal was filled with ACTIVA CEMENT and a fibre post was placed,
and after 20 seconds, it was lightcured (Fig. 12). After three years, a
radiograph showed complete bone
healing and periodontal attachment
(Fig. 13).
Conclusion
Based on the available published
research and after early favourable
results had established the effectiveness of ACTIVA BioACTIVE materials,
and based on the pH, release of calcium and phosphate ions and apatite
formation in the presence of saliva,
the decision was made to expand the
number of suitable cases. Although a
favourable outcome could not be
guaranteed, clinical cases followed
over a period of three and more
years presented with positive results
and provided evidence that the bioactive properties of ACTIVA BioACTIVE materials through their ability
to stimulate apatite formation and
osteoblasts provided a viable treatment option. The evidence has been
presented here with radiographs
and CBCT scans showing new bone
formation. Although histopathological evidence has not been provided,
a periodontal evaluation demonstrated periodontal attachment in
the cases presented here.
Editorial note: A list of references is
available from the publisher.
This article was originally published
in roots-international magazine of
endodontics, Issue 4/2018.
About the author
Dr Marta Maciak, Poland
PhD, graduated with a DDS from the
Medical University of Białystok in Poland
in 1999. In 2007, she graduated with a
specialty in conservative dentistry and
endodontics from the university’s Department of Restorative Dentistry. From 2004
to 2009, she was an assistant in the same
department. In 2009, she received a PhD
in medical sciences in dermatology. She
is a member of the Polish Dental Association and Polish Endodontic Association.
She has authored many publications, and
since 2005, she has lectured in Poland and
numerous other countries, in addition to
presenting practical training in the fields
of endodontics and aesthetic dentistry.
Her main interests are aesthetic dentistry,
endodontics and prosthetics. She can be
contacted at martamaciak2012@gmail.
com.
Five quick questions with Dr Jorge Vera
By Dental Tribune International
Dental Tribune International asked
Dr Jorge Vera five quickfire questions
about his background in dentistry
and what inspires him to practice
endodontics every day. In the interview, Vera also shed some light on
his favourite products that he uses
in his private practice and provided
some useful tips for aspiring endodontists.
Dr Vera, what is your background
in endodontics?
After finishing my DDS in Mexico,
I did my postdoctoral programme
in endodontics at Tufts University
School of Dental Medicine in Boston
in Massachusetts in the US, from
1991 to 1993, helping to teach in the
undergraduate clinic and doing
many research projects under a great
team consisting of Drs Joseph Tenca,
Robert White and Melvin Goldman.
Once I got my certificate, I returned
to practising and teaching in Mexico.
What are your three favourite
things about endodontics?
Firstly, I like the challenge of properly diagnosing and treating orofacial and dental pain, and, of course,
relieving the affected patients. And
then being able to treat symptomatic and previously endodontically treated teeth with retreatment
techniques using CBCT, the micro-
scope or endodontic microsurgery,
and returning them to functionality.
Lastly, the tremendous load of basic
science that endodontists must carry
requires continuous study to better
perform clinically in fields like pharmacology, physiology and others.
Which endo products couldn’t you
do without and why?
I would not be able to work without
a microscope and ultrasonic tips because they change the approach to
removing interferences like calcifications and previously placed materials from the root canal system in a
conservative way. Also, the use of
rotary/reciprocating instruments is
essential in my everyday practice—
their evolution is making root canal
preparation easier while maintaining more dentine—and, finally, the
use of hydraulic calcium silicate/
bioceramic cements and CBCT for
many cases.
What inspires you in your day-today work?
Being able to bring new techniques,
devices and materials into my practice about which I have learnt in
lectures and courses. Documenting their use and eventually seeing
those patients on which they were
used, heal and remain functional for
a long time. I also enjoy preparing
lectures for students and peers on
those same topics.
What is one piece of advice that
you would like to share with aspiring endodontists?
To be both open and critical about
new techniques and devices arriving on the market; to always bring
basic science into everyday practice
because therein lies the foundation
of our profession, so that whatever
we use on patients helps both them
and us; to study every single day; to
revise old notes from school and to
read the journals. Finally, it is advisable to take new courses every year.
Thank you very much for the
interview.
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HANDS-ON COURSE
26-27 March 2020
Thursday-Friday
09:00 - 18:00
•
•
•
•
CAPP Training Institute
Dubai | UAE
Area of interest:
Endodontics
28-29 March 2020
Saturday-Sunday
09:00 - 18:00
AED 4,400
$ 1,200
CAPP Training Institute
Dubai | UAE
Area of interest:
Endodontics
Dr. Antonis Chaniotis, Greece
Prof. James Prichard, UK
He currently serves as an active member of the Hellenic Society of
Endodontology and the Academy of Microscope Enhanced Dentistry
and is a certified member of the European Society of Endodontology.
Visiting Professor and Programme Leader, MClinDent in Endodontology at BPP University.
Course Objectives
Course Objectives
DAY 1 - Delegates will be able to:
DAY 1 - By the end of the course delegates will understand:
Remove guttapercha obturations from root canals.
Remove Carrier based obturations from the root canals.
Remove paste obturations and remove fiber posts.
Have the oportunity to use most of the current technology used during retreatment
procedures.
DAY 2 - Delegates will be able to:
• Bypass and remove broken endodontic files.
• Understand all the preventive measures to avoid complications during endodontic
instrumentation.
• Repair a pulp floor perforation.
• Obtutrate an internal resorption defect.
• Perform apical plugs with biocompatible materials.
www.cappmea.com/courses
CONTACT
CAPP EVENTS
Onyx Tower 2 | Office P204 & P205
The Greens | Dubai | UAE
Mob/WhatsApp: +971502793711
Tel: +971 4 347 6747
E-mail: events@cappmea.com
Web: www.cappmea.com
AED 4,400
$ 1,200
ACCREDITATION
Est. DHA 12 CME
CAPP designates this activity for 14 CE Credits
•
•
•
•
•
•
•
•
Outcomes of endodontic microsurgery vs traditional apicectomy.
The science behind effective local anaesthesia in endodontic microsurgery.
The use of a dental operating microscope in endodontic microsurgery.
Flap design and tissue handling to improve post-surgical healing.
How to effectively prepare an osteotomy.
Correct methods of ultrasonic root-end preparation and how to identify anatomical markers.
Which equipment is appropriate for use in micro-surgical techniques.
Effective suturing and postoperative care including analgesia.
DAY 2 - By the endo of the course delegates will have:
•
•
•
•
•
•
•
Been calibrated to a dental operating microscope.
Have identified cases where surgical intervention is appropriate.
Have raised a flap with microsurgical instruments.
Created an osteotomy and identified anatomical markers.
Performed root end resection and retrograde preparation of the root canal space.
Performed microsurgical suturing.
Developed a post-operative care strategy to minimize complications and improve healing.
www.cappmea.com/courses
CONTACT
ACCREDITATION
CAPP EVENTS
Onyx Tower 2 | Office P204 & P205
The Greens | Dubai | UAE
Mob/WhatsApp: +971502793711
Tel: +971 4 347 6747
E-mail: events@cappmea.com
Web: www.cappmea.com
CAPP designates this activity for 14 CE Credits
Est. DHA 12 CME
[4] =>
DTMEA_No.5. Vol.9_ET.indd
Dentsply Sirona Endodontics
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