Case Studies 04_Mise en page 1 25/02/13 12:11 Page1

Case Studies
Septodont

No. 04 - March 2013 Collection

Focus on:
BIODENTINE™
TREATMENT OF TRAUMATIZED INCISORS
RITA CAUWELS
N'DURANCE® CRISTAL
CHOICE FOR CLINICAL SUCCESS
MARKUS FIRLA
BIODENTINE™
PERFORATION REPAIR
GODFREY CUTTS
BIODENTINE™
DEEP CARIES TREATMENT
OXANA DENGA
Case Studies 04_Mise en page 1 25/02/13 12:11 Page2

Since its foundation Septodont has developed, manufactured

and distributed a wide range of high quality products for
dental professionals.

Septodont has recently innovated in the field of gingival

preparation, composites and dentine care with the intro-
duction of Racegel, the N’Durance® line and Biodentine™,
which are appreciated by clinicians around the globe.

Septodont created the “Septodont Case Studies Collection”

to share with you their experience and the benefits of using
these innovations in your daily practice.
This Collection consists in a series of case reports and is
published on a regular basis.

This fourth issue is dedicated to two of these innovations:

Biodentine™: the first and only dentin in a capsule.
Biodentine™ uniqueness not only lies in its innovative
bioactive and ‘pulp-protective’ chemistry, but also in its
universal application, both in the crown and in the root.

N’Durance® Cristal : innovative composite based on our

exclusive Nano-Dimer Technology. N’Durance® Cristal
offers a selection of shades, designed for high-end
anterior restorations, combined with both a low
shrinkage and a high conversion.

This issue features case studies written by clinicians from

4 countries: Belgium, Germany, Ukraine and UK, illustrating
the success of our innovations in a growing number of
countries.

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Content
Biodentine ™ Pulp therapy of traumatized
immature incisors 04
Dr Rita Cauwels

N’Durance® Cristal composite:

A practitioner’s choice for clinical success 09
Dr Markus T. Firla

Repair of a perforation of the floor of the

pulp chamber with Biodentine™ 14
Dr Godfrey Cutts

Clinical effectiveness of acute deep

caries treatment 16
Prof Oxana Denga

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Biodentine™
Pulp therapy of traumatized
immature incisors
Dr Rita Cauwels
University of Ghent, Belgium

Introduction
Worldwide, the proportion of maxillofacial trauma introduced as a material for apexification in a
in relation to all types of trauma varies from 9% single visit, showed to cover some of the draw-
to 33%. From all dental injuries 75% are related backs of CH.6 Biocompatible and bioactive
to the upper central incisors. The peak incidence properties of MTA as apical plug have been
of dental trauma in the permanent dentition is demonstrated in several studies.7,8 Despite the
seen at 8 to 10 years of age.1 The treatment of formation of periapical abscesses with extensive
pulpal injury during this period provides a signi- periradicular bone resorption as a result of root
ficant challenge for the clinician. At this particular canal infection in immature teeth, clinical studies
age, the permanent incisors are not fully matured, using MTA reported conservative treatment allo-
characterized by an open apex and thin dentinal wing further root development.9,10,11 However,
walls as a consequence of a wide flaring root because of its low mechanical properties, no
canal. Depending upon the vitality of the affected strengthening effect was seen in weakened
pulp, two approaches are possible – apexoge- immature roots. Possible coronal discoloration
nesis or apexification.2 Apexogenesis is a vital after pulpotomy and long setting time are other
pulp therapy procedure performed to encourage drawbacks of MTA.
continued physiological development and forma- Biodentine™, a comparable tri-calcium silicate,
tion of the root end. In case of pulp necrosis, has been developed as a dentine substitute in
apexification is the treatment of choice inducing deep cavities. Comparable to MTA, Biodentine™
a calcified barrier in a root with an open apex or is biocompatible and in contact with vital tissues
the continued apical development of an incom- it has been demonstrated to be biologically
plete root. 2 Although the success rate of active. In contrast with MTA, the material proper-
apexification with calcium hydroxide is 95%, its ties of Biodentine™ are similar to those of
long-term prognosis appears to be compromised dentine. The compressive strength and elasticity
by cervical root fractures.3,4 These fractures are modulus are comparable with dentine (Septodont;
strongly related to the stage of root development internal data). Moreover, no coronal discoloration
and defects at the cervical area.4 However, this has been reported. The material sets in
observation was also explained by the fact that 12 minutes and is capable to withstand dete-
long-term use of calcium hydroxide has a weake- rioration when used as a temporary filling.
ning effect on dentin due to a proteolytic reaction. Thanks to the excellent mechanical properties,
In the early nineties, an alternative material comparable to those of dentine, Biodentine™
based on calcium silicate, mineral trioxide aggre- can be advised in weakened immature teeth.
gate (MTA), has been introduced. 5 MTA,

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Case Report no.1

Apexification
A 9-year old girl was referred for treatment of
pulp necrosis in an immature 21 as a conse-
quence of a mild dental trauma a few weeks
before. The immature maxillary central incisors Fig. 1.1: One visit Fig. 1.2: Complete canal
11 and 21 were involved. At that time, as Bioden- apexification with MTA and filling of 11 with Biodentine™.
gutta percha of 21.
tine™ was not available yet, an MTA plug was
placed for apexification with gutta-percha on Fig. 1.3: X-ray at 6 months
follow-up of 11 filled with
top of it (Fig. 1.1). Three months later tooth 11 Biodentine™ and 9 months
was also diagnosed with a necrotic pulp. After follow-up of filled with 21
MTA plug + gutta-percha.
traditional rinsing of the canal with NaOCl but
no instrumentation, 11 was filled with calcium
hydroxide for 1 week awaiting a treatment with
Biodentine™. In a second visit, the endodontic
canal was obturated over the entire length with
Biodentine™ (Fig. 1.2). No post-operative pain
was reported. At 6 month follow-up no pathology
was noticed on x-ray (Fig. 1.3). However, clinically,
a light discoloration was observed for 21 which
was treated with MTA (Fig. 1.4). It is known that
MTA can be responsible for crown discoloration,
in this case probably due to remnants of MTA
at the cervical area. No pathology was seen at
the apical zone in both incisors.

Fig. 1.4: Clinical view of 11 (Biodentine™) and 21 (MTA plug)

revealing a light crown discoloration of 21.

Case Report no.2

Apexification
A 9-year old boy was referred for treatment
of an endodontic infection in 11. Ten
months before, at the age of 8, he under-
went a dental trauma resulting in luxation
of 11 and 21 with uncomplicated enamel-
dentine fractures and increased mobility.
Both traumatized teeth were splinted for 2
Fig. 2.1: Fistula (arrow) buccal from 11.
weeks and restored with composite. Clinical
examination revealed the presence of a fistula
at the buccal side of 11 (Fig. 2.1). An x-ray Fig. 2.2: Stop of root
showed an asymmetric development of both development of 11 due to
pulp necrosis.
central incisors and a radiolucency at the apex
of 11 (Fig. 2.2). This incisor remained in an

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Fig. 2.5: Clinical view after

2 months showing healing.

Fig. 2.3: 11 intermediate filled Fig. 2.4: 11 filled with Fig. 2.6: A gradual resorption of
with calcium hydroxide. Biodentine™ and showing an the extruded material and
important apical extrusion of healing of the apical granuloma
the material. was observed.

immature stage (open apex) revealing an arrested Biodentine™ (Fig. 2.4). An x-ray showed apical
development due to pulp necrosis. In a first perforation of Biodentine™. No post-operative
approach, the incisor was opened and endo- pain or tenderness was reported. After two
dontically rinsed with NaOCl in order to remove months, clinically, the fistula disappeared and
necrotic tissue. The canal was then dried and healing occurred (Fig. 2.5). A gradual resorption
filled with calcium hydroxide paste for 2 weeks of the extruded material was shown in a radio-
(Fig. 2.3). In a second setting, after removing graph (Fig. 2.6).
calcium hydroxide, the canal was filled with

Case Report no.3 - Apexogenesis

A 7-year old boy
presented with a
complicated crown
fracture of 21. During
sport activity he frac-
tured his tooth (Fig. 3.1).
The 21 was tender to
percussion and the Fig. 3.3: X-ray revealing
apexogenesis of both incisors
pulp was exposed. during follow-up procedure.
Local anesthesia was Fig. 3.2: Biodentine™ Biodentine™ was superficially
covering the pulp and left as replaced by a composite
injected and the frac- Fig. 3.1: Complicated crown restoration.
a temporary filling.
ture side cleaned with fracture of 21, involving the
saline solution. The dental pulp. composite restoration. During this second visit,
exposed pulp was covered in immediate contact the patient did not complain from tenderness
with a layer of Biodentine™, which was simul- anymore. No pain was reported after the first
taneously left as a temporary filling (Fig. 3.2). visit. The x-ray did not reveal any sign of patho-
Four weeks later, a superficial layer of Bioden- logy. During the follow-up procedure, figure 3.3
tine™ was removed using a high speed diamond shows a symmetrical apexogenesis of both
bur under water coolant and replaced by a central incisors.

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Fig. 4.1: Abscess and apical Fig. 4.2: Calcium hydroxide Fig. 4.3: Biodentine™ filling in Fig. 4.4: Apexogenesis after 6
radiolucency of 21 dressing in 21. 21. months follow-up.

Case Report no.4

Apexogenesis
A 6-year old boy was referred for treatment of
an abscess of 21. He experienced a dental
trauma 2 weeks before. A non-complicated Fig. 4.5: Apexogenesis after Fig. 4.6: Clinical view of both
18 months follow-up. incisors after 18 months of
crown fracture of 21 was diagnosed. Clinically treatment.
he had a painful swelling buccally from 21 and
pus was released from the sulcus during palpa- paste was left for 3 weeks in immediate contact
tion. No pulp exposure however was present. with the remaining tissue (fig. 4.2). During the
The tooth showed an increased mobility and next visit, no clinical symptoms were present.
was tender to percussion. No sensitive reaction Patient did not suffer anymore from pain, no
was felt in contact with cold stimulus, presuming swelling and the element showed again normal
complete pulp necrosis. X-ray revealed a highly mobility. Calcium hydroxide had to be repeated
immature incisor 21 with an important apical and left for another week due to persistence of
radiolucency (Fig. 4.1). After injection of local humidity in the apical third. In the next session,
anesthesia, the 21 was opened and pus was calcium hydroxide was replaced by Biodentine™
released. The canal was thoroughly rinsed with (Fig. 4.3). Radiographic follow-up at 6 (Fig. 4.4)
NaOCl in order to remove necrotic tissue and and 18 months (Fig. 4.7) showed an ongoing
remnants and finished by a saline solution apexogenesis of 21, comparable to the
rinsing. After drying the canal, calcium hydroxide untreated 11 (Fig. 4.8).

Conclusion
Biodentine™ can be seen as the most appro- infection healing was apparent. Moreover, in
priate material to treat endodontic compromised two cases further root development was shown.
permanent immature teeth. No crown discolo- Regarding the mechanical properties, it is
ration is seen, even not when the material is assumed that Biodentine™ can withstand
placed coronally. No post-operative pain was normal functional stresses in order to preserve
reported, moreover, clinical and radiographical the tooth.

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Author: Rita Cauwels

Rita Cauwels graduated in 1980 and ran a general practice focusing on
paediatric dentistry. In 1997 she received her MSc in Paediatric Dentistry and
Special Care from the Ghent University. For many years she contributed
regularly to the congresses of IADH, IAPD and EAPD. Dr Cauwels is actual
council member of IAPD for Belgium. Since 2002 she has been working as a
full-time clinical assistant at the department of Paediatric Dentistry focused on special care
at the University Hospital Ghent and is a member of the PaeCaMed research group. She
completed her PhD thesis on dental traumatology in collaboration with the University of
Turku (Finland). One of her clinical interests includes laser treatment in paediatric dentistry
and Low Level Laser therapy in oncology patients.

References
01. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth.
4th edn. 2007 Blackwell Munksgaard. ISBN 978-1-4051-2954-1.

02. Rafter M. Apexification: a review. Dent Traumatol 2005; 21: 1-8.

03. Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in non-vital
immature permanent teeth: a review. Br Dent J 1997; 183: 241-6.

04. Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with
gutta-percha. A retrospective clinical study. Endod Dent Traumatol 1992; 8: 45-55.

05. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a
root end filling material. J Endod 1993;19:591-595.

06. Bakland LK, Andreasen JO. Will mineral trioxide aggregate replace calcium hydroxide in treating pulpal and
periodontal healing complications subsequent to dental trauma? A review. Dent Traumatol 2012;28:25-32.

07. Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR, Miller DA, Kariyawasam SP. Histologic assessment
of mineral trioxed aggregate as a root-end filling in monkeys. J Endod 1997;23:225-228.

08. Torabinejad M, Hong C-U, Lee S-J, Monsef M, Pitt Ford TR. Investigation of mineral trioxide aggregate for
root-end filling in dogs. J Endod 1995;21:603-608.

09. Iwaya SI, Ikawa M. Revascularization of an immature permanent tooth with apical periodontitis and sinus
tract. Dent Traumatol 2001; 17: 185-187.

10. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment
protocol? J Endod 2004; 30: 196-200.

11. Garcia-Godoy F, Murray PE. Recommendations for using regenerative endodontic procedures in
permanent immature traumatized teeth. Dent Traumatol 2012; 28: 33-41.

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N’Durance® Cristal composite:

A practitioner’s choice for clinical
success
Dr Markus T. Firla
Private practice, Germany

Septodont’s innovative composite system N’Durance® Cristal - now recently marketed

as a continuous material improvement on Nano-Dimer-technology-based N’Durance® -
is a “restorative of choice” for all clinical cases when esthetic demands, material
properties and handling characteristics are to meet high-end quality direct restorations.

N’Durance® Cristal
The universal composite N’Durance® Cristal is Ethoxylate-dimethacrylate (EBPADMA) and
based on the polymer technology of nano-dimer Urethane dimethacrylate (UDMA), a well-
conversion. Since the introduction of the compo- established monomer with a solid track record,
site restoration material N’Durance® by Septodont, and finally
this technology has acquired an important clinical Polymerization-induced phase separation
place among composite restoration materials. (PIPS). This phenomenon describes the
Right from the beginning, trials carried out at process of significantly reduced polymerization
the University of Leuven by Prof. Lambrechts shrinkage of the monomer molecules during
and the University of Denver, Colorado by Prof. the curing phase. At the onset of polymeriza-
Newman demonstrated the many promising and tion of these monomer molecules there is a
positive material properties of this new improved gradual separation of the initially completely
composite material technology. miscible molecules leading to two-phase
separation within the organic synthetic resin
The improved material characteristics are based matrix.
in particular on:
Nano-dimer-conversion technology and a Furthermore, the length of the monomer molecule
carefully balanced mix of dimethacrylate present in the synthetic resin matrix containing
monomers that form the synthetic resin matrix, a moiety of dimer-dicarbamate-dimethacrylate
Dimer-dicarbamate-dimethacrylate (“dimer also has a positive impact on the dramatically
acid”, DDCDMA), a proprietary monomer, reduced polymerization shrinkage. The dimer

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acid molecule is approximately 50% larger than detail about the material, but it should be noted
the simple methacrylate monomer molecule that its hydrophobia – a primary property of the
found in many conventional composites. material – is largely attributable to the chemical
The complete chemical reaction called “nano- structure of the dimer-dicarbamate-dimethacry-
dimer-conversion technology” by the manufac- late molecules.
turer therefore finds its full utility in this
restorative material. It is particularly noteworthy The reduced water sorption of the composite
in terms of its physical properties that a reduction material described above ensures that fewer
in general polymerization shrinkage also lessens constituents are washed out of the filler material.
polymerization-induced shrinkage stress in the This means that the clinically relevant physic-
composite filling material. This is all the more mechanical material properties are more durable
important since it is the shrinkage stress in in the long-term.
hardened composite that actively hinders
complete micro-retentive adhesion of restoration
material to dental enamel, giving way sooner
or later to micro-leaks and substance loss Excellent clinical
along the bond between the composite and
dental enamel. performance
High level of polymerization N’Durance® Cristal is available in the most
The high polymerization level of this universal common shades A1, A2, A3, A 3.5, B1, B2, C2
composite system also has an important clinical and as the universally applied enamel shade
role. Due to the chemical properties of the Incisal.
dimer-dicarbamate-dimethacrylate molecules, The clinical material parameter “user friendliness”
which are able to move more freely and unres- is of particular importance for both the operator
trictedly than conventional monomers during and the patient, and has a very positive impact.
the polymerization process, a polymer crosslink In the author’s opinion, based on 27 years of
rate (conversion level) of approximately 80% is experience with intraoral adhesive preparation
achieved under normal curing light. Most other of direct composite filling materials, the following
composite filling materials have values ranging points are of key importance:
from only 45 to 65% at most! high polishability,
very good color match to the patient’s enamel
Biocompatibility easy handling
This high conversion rate gives rise to far lower Although this restoration material is relatively
residual monomer content in the hardened viscous it is still very easy to apply from the
composite, which in turn means considerably screw syringes and single dose capsules. Its
fewer monomers being released from the filling relatively high viscosity makes it ideally suited
material. The lower the rate of monomer release to modelling applications in class III and IV
from a composite material, the lower the risk of anterior cavities and for “packable” filling in
adverse biological reactions to the material. posterior defects.
This clearly diminishes the risk of toxicity and Impressive radiopacity
allergic reactions. Finally, it is also important to mention the
surprisingly high radiopacity of this composite
Marked hydrophobia material system with an aluminum equivalent
And last, but not least, mention must be made level of almost 4 mm.
in this report of the marked hydrophobia of the
special synthetic resin matrix. To keep this
presentation succinct we will not go into greater

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Clinical case no.1

Figures 1 to 3 show an emergency treatment the “bulk technique.” We therefore applied a
of a maxillary left central incisor. The young single layer of N’Durance® Cristal, shade A2.
woman came to the practice without an Despite the time-consuming preparation of
appointment after an approximately 12-year- the enamel surface with 35% phosphoric acid
old composite build-up had broken off without followed by application of a self-conditioning
apparent cause while she was eating lunch. all-in-one adhesive - both of which were neces-
In order to give the patient a “first-aid” treatment sary for adhesion - the treatment only took
as quickly as possible, and because we were 12 minutes from start to finish, including contou-
short of time, her treatment having been ring and surface-polishing the filling. The speed
“squeezed” into the routine treatment schedule, at which we were able to do owed much to
we decided to carry out an adhesive direct the excellent esthetic and physic-mechanical
monochromatic composite restoration using material properties of N’Durance® Cristal.

Fig. 1 Fig. 2 Fig. 3

Fig. 1-3: Emergency treatment of a left central incisor’s fractured off incisal portion (Fig.1). The adhesive composite restoration was
executed by simply applying a one-layer bulk-incrementincrement of N’Durance® Cristal, color shade A2, without any mechanical
preparation on the tooth’s surface (Fig.2). The whole restorative process – including contouring the restoration, light-curing, trimming
and finishing, and adjusting the filling to proper occlusion – took only 12 minutes (Fig.3)

Fig. 4
Clinical case no.2
This case shows a routine, planned filling treat-
ment of the maxillary central incisors before
(Fig. 4) and after treatment (Fig. 5). Due to the
positive esthetic properties of N’Durance® Cristal
we were able to carry out all eight restorations
Fig. 5 using only a single composite material. Shade
A3 of N’Durance® Cristal was used for mono-
chromatic filling of the individual cavities. Its
excellent handling properties meant we were
able to complete the entire filling treatment to
the maxillary central incisors within only
30 minutes.
Fig. 4-5: Multiple approximal carious lesions in upper front teeth (Fig. 4). Given a sensible, regular clinical time frame of 45 minutes for all
eight restorations – in accordance with the author’s rules of scheduling restorative treatments – an easy-to-handle, esthetically reliable
composite material is essential for success.
N’Durance® Cristal composite, color shade A3, was used for all eight restorations in a one-layer-technique. This particular composite—
specially conceived for anterior high-end quality restorations-is designed for “monochromatic” fillings that blend in perfectly with the
visual appearance and color impression of natural tooth substance.

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Clinical case no.3

Replacing an insufficient corner build-up on a layer technique.” First, we applied a palatinal-
right maxillary central incisor to improve the incisal base layer of N’Durance® Cristal in shade
overall esthetic impression (Fig. 6) was a consi- A3.5 (Fig. 8). Once we had extensively light
derable challenge, because the 17-year-old girl cured this relatively dark composite material
was very critical and had high esthetic expec- the second composite layer was applied labially.
tations. It was important to preserve exactly the N’Durance® Cristal Incisal was used for this
same shape of the tooth with the new filling. To material layer, since it has the most esthetic
achieve this we used an intraoral A-silicone impact.
plug assist to obtain an individual impression The very good polishing properties of all
and ensure that the tooth shape was identical N’Durance® Cristal products enabled us, by
in the reconstruction (Fig. 7). To ensure that the contouring and polishing the filler surface, to
color and light impression of the direct, adhesively create a “biomimetic” surface rapidly and easily
applied composite restoration was completely (Fig. 9).
optimal we decided to proceed using the “dual

Fig. 6 Fig. 8

Fig. 7 Fig. 9

Fig. 6-9: Esthetically invalid composite Class-IV-restoration in a young woman’s right upper central incisor (Fig. 6). In order to achieve a
fully acceptable esthetic result it was decided – in accordance with the patient’s wishes – to refer to the two-layer-technique involving a
custom-made matrix (Fig. 7) when restoring the teeth with direct adhesive composites. N’Durance® Cristal, shade A 3..5, was applied as
a first, shape-giving layer due to its excellent physical estheticc properties, e. g. “biomimetic” tooth color, life-like translucency and color
stability after light curing (Fig. 8). The second, i.e. final, layer was applied with the same composite’s most translucent, universally usable
shade Incisal. This restorative’s superb tooth color matching, blending-in properties (“chameleon effect”), along with the outstanding
polishability of all N’Durance® composites, allow these high-end esthetic restorations to be completed in only a short time (Fig. 9).

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Author: Dr Markus T. Firla

Hauptstrasse 55
D-49205 Hasbergen-Gaste - Germany
Email: [email protected]

Dr Firla has been a dentist for 20 years, managing his own practice since 1994,
which has attained certification in ISO 9001:2000 (Requirements for Quality
Management Systems) and EPA-Dent (European Practice Assessment for
Dentistry) standards

References
01. Barfuß A: Unsichtbar – Eine Rekonstruktion aus Komposit. Interview with Dr Oliver Kappler. Dent Mag
2011; 28: (!) 38-41.

02. Firla M T. Ästhetische Aspekte zur biomimetischen Schichttechnik. Zahnärztl Mitteil 1990; 80: (18) 1957-1962.

03. Firla M T. Biomimetische Kompositrestaurationen. DZW 2005; 19: (39) 22-23.

04. Firla M. T.: Direkte „einfache“ biomimetische Frontzahn-Komposit-Restaurationen. Dent Barometer 2010;
5: (6) 38-41.

05. Firla M Th: Hohe Biokompatibilität und gute werkstoffkundliche Eigenschaften bei Kompositen. DZW 2010;
24: (13) 17-19.

06. Firla M Th: Komposite auf Dimer-Säure-Basis. DZW Spezial 2010; 18: (2) Sonderdruck 1-3.

07. Mahn E: Die richtige Wahl bei Frontzahnfüllungen. Dentalzeit 10: (1) 36-38

08. Newman S M: Eine neue Technologie für Komposit-Füllungsmaterial. ZWR 2009; 118: 648-653.

09. Ozoglu A H: Minimalinvasiv restauriert. Dent Mag 2011; 28: (1) 44-46.

10. Roeters J, de Kloot H. Kosmetische Zahnheilkunde mit Hilfe von Komposit. – Praktische Anwendung der
direkten Technik. Quintessenz Verlag Berlin, 1992.

11. Septodont: N’Durance® – Nano-Dimer Conversion Technology. Technisches Produktprofil DVD 2009.

12. Septodont: N’Durance® – Product information. 2009; Brochure.

13. Septodont: N’Durance® Cristal – Nano Dimer Technologie. Scientific File; 2012.

14. Trujillo-Lemon M et al: Dimethacrylate derivates of Dimer Acid. J Polymer Science Part A: Polymer
Chemistry 2006; 44: 3921-3929.

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Repair of a perforation
of the floor of the pulp chamber
with Biodentine™
Dr Godfrey Cutts
Private practice, United Kingdom

A 43 year old female patient was referred for possible endodontic treatment to 26 by her
dental practitioner who states in the referral letter (Fig 1) that there is a possible
perforation of the floor of the pulp chamber which has been “ temporised with amalgam”

Fig. 1

Upon examination there was some buccal chamber and a considerable amount of amalgam
tenderness and the tooth was slightly tender to in the furcation.
percussion. Radiographic examination (Fig. 2) Local anaesthetic was administered and the
demonstrates loss of the floor of the pulp tooth isolated with rubber dam. After removal
of the coronal temporary dres-
sing the extent of the perforation
was revealed and involved the
whole of the floor of the pulp
chamber including the orifice of
the palatal and disto-buccal
canals. (Fig. 3)
The amalgam could not be
Fig. 2 Fig. 3 removed intact since it was

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Fig. 4 Fig. 5 Fig. 6

convex and locked in the furca-

tion. With judicious use of
ultrasonic instruments from the
“Satelec” EndoSuccess range
the amalgam was gently frag-
mented and the majority
removed.
Fig. 7 Fig. 8

The initial treatment plan was to carry out At the second visit one week later the access
conventional endodontic treatment before repai- cavity was re-opened (Fig. 7/8) to perform conven-
ring the perforation however this was not possible tional endodontic treatment with GIC used to
since the irrigants were leaking through the restore the floor of the access cavity followed
furcation and past the rubber dam. Repair of by a bonded amalgam core, the tooth was
the perforation became the priority and this removed from the occlusion and the patient was
was carried out using Biodentine from Septodont. advised to have a full coverage crown as soon
Before attempting the repair a paper point was as possible.
placed in the disto-buccal canal to preserve
patency. The perforation was dried gently using
large paper points before placing the Biodentine This case can be viewed
passively in increments using a Thymozin instru- on youTube :
ment.( Fig. 4/5/6) Upon completion of repair of
the perforation the Biodentine was allowed to http://www.youtube.com/watch?v=bLR8Lsm_zKo
set for 10 minutes before temporisation of the
access cavity.

Godfrey Cutts LDS Dunelm.

Graduated from the Sutherland Dental School, Newcastle upon Tyne in 1961.
In general practice as a GDP in Nuneaton Warwickshire from 1964 until the present day.
In 1968 the practice was sold to Oasis Dental Care and has held posts with the company
as Clinical Director and Clinical Advisor.
Has a special interest in endodontics and has attended numerous courses including
those held at the Eastman Dental Institute and is a member of the British Endodontic
Society attending their meetings on a regular basis. In the past eight years he has
organised and lectured at hands on courses for GDP’s at venues around the country.
Has an active interest in developing new instruments, materials and protocols for their use to enhance
treatment outcomes.
In 2005 he filmed and produced the instructional DVD for the use of RaCe Ni-Ti files.
Currently he has a successful endodontic referral practice, treating some 500 cases a year, where
practitioners from some fifty miles around refer patients for initial treatments, re-treatments and apical
micro-surgery.
[email protected]

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Clinical effectiveness of acute

deep caries treatment
in patients with compromised allergic history
using a novel calcium silicate material
Prof O.V. Denga, Dr M.V. Anisimov, Dr L.V. Anisimova
SE “Institute of Stomatology of the NAMS of Ukraine”

Acute deep caries treatment with a step-by-step approach for patients with a compromised allergic
history using “Biodentine™” (Septodont) is suggested. The clinical observations were performed
on 40 patients. Thirty mandibular molars were treated in each group. The use of clinical-radiological
and spectro-colorimetric techniques demonstrated the advantages of the chosen method of
treatment in these patients.

allergic to latex rubber dam as well [2, 4]. This

Introduction fact makes the treatment of this category of
patients more complicated.
Earlier conducted research showed that 22.5%
of all dental patients have allergic compromised
history [1]. At the same time, it was observed
that these allergic compromised patients have Objectives
a higher intensity of caries and lower level of
non specific resistance [2, 3]. The main risk Evaluation of the clinical effectiveness of the
group with drug allergies represents the main proposed “step-by-step” treatment of acute
risk group for the use of local dental anaesthetics. deep caries in patients with a compromised
Most of the people from this group are also allergic history with “Biodentine™”.

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Methods and materials

For the comparative effectiveness of caries with distilled water and drying it with cotton
treatment there were two groups of patients: 21 pellets, Biodentine™ (Septodont) was placed
patients in the test group and 19 patients in the into the cavity for a period of 48 hours. During
control group. In each group 30 mandibular the second visit the upper layer of the Biodentine
molars were treated. was cut down (2-3 mm) and the enamel was
The treatment was performed by one dentist. In permanently restored with “Grandio” (VOCO)
the control group the treatment was completed composite material. The fissures and blind
using the invasive-restorative methodology fossae were filled with a pit and fissure sealant:
according to the standard procedure. We used “Fissurit” (VOCO).
“Calcimol LC” (VOCO) as a liner. The glass- The defects and complications were recorded
ionomer cement “Vitrebond” (3M ESPE) was on the basis of patients’ complaints, clinical
used as an isolating liner. The crown build up examination in conjunction with roentgenograms.
was achieved with “Grandio” (VOCO) in combi- To evaluate the level of hard tissues mineralization
nation with “Futurabond” (VOCO) as bonding during the deep acute caries treatment with
system. Biodentine™, we used the spectro-colorimetric
The deep caries treatment in the test group observations method by O.V. Denga [5].
was carried out in two steps. During the first All the optical and color parameters were
visit the patient had his cavity prepared (without recorded in the color coordinates, in the form of
local anaesthesia) in accordance with the principle spectral distribution of the hard tissues’ reflection
of prophylactic filling. After toileting the cavity coefficient.

Results of the research

During the dental treatment of patients with general anaesthesia is not always necessary
allergic compromised history, we also observed during the dental procedure.
in some instances an intolerance/ reaction to Hypo-allergic and highly technologic material,
latex rubber dams, sodium hypochlorite solution, Biodentine™ was used as a dentin substitute
thymol, and formocresol. material. Thanks to its chemistry, that contains
Taking into account the fact that these few mineral ingredients without monomers, Bioden-
unsatisfactory results were observed during the tine™ became the material of choice for this
treatment without using local anaesthetics [6], treatment. According to the manufacturer’s
we should improve the existing treatment algo- instruction, this material can be applied directly
rithms. into the tooth cavity without the previous cleaning
For the caries treatment of dental patients with of the surface from the calcified tissues. By
drug allergies, we suggested a two-visit approach. means of the total “sealing” of the dentin surface,
First the prophylactic filling of fissures, that the usage of this material can be a good back-
involves a conservative preparation of the hard ground for pulp vitality preservation.
tissues at the level of the damaged enamel and The clinical efficacy was evaluated during the
dentin tissues, followed secondarily by the following year. The clinical-radiological exami-
fissures and the blind fossae sealing. This point nation demonstrated the advantages of the
is very important for us, as the patients with chosen method for these patients. There were
drug allergies have a contra-indication to the no cases of inefficient treatment in the test
use of local anaesthesia and the use of the group of patients.

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Case Studies 04_Mise en page 1 25/02/13 12:11 Page18

As for the control group, we observed three reflection coefficient with the wave length in the
cases of secondary caries, in three more cases range of 450-480 nm was decreased by 2.6 times
we observed poor marginal integrity, and in one (Fig. 1).
case we observed the loss of the restoration.
There were no complications in the form of
periodontitis or pulpitis observed.
The initial rate of the hard tissue mineralization
was the following: (10+1)x 10-4 gradR. Nm-4
At 12 months, the analysis of the spectral Fig. 1: Spectral
distribution of the light reflection coefficient in distribution of the light
reflection coefficient of the
the treated teeth showed a significant increase tooth 46 (curve 1- before
of the hard tissues mineralization, which was at the treatment, curve 2- 1
year after the treatment).
the level of (3,8+2)x104 gradR. nm4. The light

Extract from the medical report

Patient N., born in 1985 came complaining in the form of short termed pain; probing was
about short term pain stimulated by chemical painless, percussion was painless as well. EOD:
and thermal stimuli. The tooth had been aching 5.8 MkA (apparatus PULPTEST).
for one month. Diagnosis: Acute deep caries of tooth 46.
The medical history states an anaphylaxis of Treatment procedure: the conservative prepa-
the second stage 5 years before during dental ration of the cavity was held without using local
treatment. The laboratory diagnosis was held: anaesthetics (Fig. 2). The cavity was rinsed with
IFA (immune fermentative analysis) special- distilled water and dried with a cotton pellet.
articaine 2.26 ME/ml, mepivacaine -3,23 ME/ml, Biodentine™ was applied into the cavity (Fig. 3).
lidocaine – 1,16 ME/ml. The use of local anaes- After 8 months the patient came back for the
thetics was therefore contraindicated. second visit. There were complaints. On the
Objectively: there is a carious cavity on the roentgenogram on the cavity bottom there were
occlusal surface, in the limits of circum-pulpar clearly noticeable “dentine bridges” (Fig. 4). The
dentin of tooth 46, with a narrow entrance that upper layer of the “artificial dentine” was removed
is observed by the loose slightly pigmented (Fig. 5) and the complete restoration was made
tissue. There was a reaction on a thermal irritant using “Grandio” (VOCO) (Fig. 6).

Fig. 2: Acute deep caries of tooth 46 Fig. 3: The tooth is filled with “Biodentine™”

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Case Studies 04_Mise en page 1 25/02/13 12:11 Page19

Fig. 4: Roentgenogram of the tooth 46 after 8 months. The Fig. 5: The upper layer of “Biodentine™” is removed
“dentine bridges” are clearly seen on the cavity bottom

Conclusion
The clinical-radiological and spectro-colorimetric
observations proved the advantages of the treat-
ment method of such category of patients.
There were no cases of ineffective caries treat-
ment results in the test group of patients observed
during this year. The level of the hard tissues
mineralization increased sufficiently: from (10+
1)'10-4 grad R, nm-1 to (3.8+ 2) '10-4 gradR,
nm-1 for the light reflection coefficient, with the
wave length in the range of 450-480 nm.
We recommend using “Biodentine™” for treat-
Fig. 6: Tooth 46 after treatment ment of patients with a drug allergy risk.

Professor Denga Oxana

Honored doctor of Ukraine,
Doctor of Dental Science (DDS)
Professor, chairman of the Pediatric Dentistry Division (Scientific institute of dentistry,
Academy of Medical Sciences of Ukraine)
Chairman of the Pediatric Dentistry Department (Odessa State Medical University)
Head of the Regional Pediatric Dentistry and Orthodontic Center
Vice-president of the regional section “Pediatric dentistry” of the Ukraine Association of
Dentists (ASU),
President of the Ukrainian Dental Hygienists Association
Member of the International Association of Paediatric Dentistry (IAPD)
Member of the European Association of Dental Public Health (EADPH)
Member of the International dental Collage (ICD)

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References
01. Anisimov M. V. Prevalence of allergic reactions conditioned by usage of local anesthetics. / Anisimov M. V.,
L.V. Anisimova // Conference proceedings “Scientific and practical aspects of individual and professional
oral hygiene”. – Odessa, 2009. – P. 9-10.

02. Admakin O. I. Oral health status of children and adolescents with allergic pathology / O. I. Admakin,
N. A. Geppe, Ad. A. Mamedov, D. A. Baysagurov // Dental forum. – 2005. – N°4. – P. 30-35.

03. Achmerova A. Ph. Clinical progression characteristics and prevention of caries and periodontal diseases
in children with allergosis: Candidate's dissertation / A.Ph. Achmerova. – Kazan, 2001. – P. 133.

04. Veber V. R. Local anesthesia in dental patients with comorbidity: Tutorials / V. R. Veber, B.T. Moroz. –
SPb.: Human, 2004. – 80 pages.

05. Denga O. V. Adaptogenic prevention and treatment of pediatric dentistry diseases: synopsis of PhD
thesis: specialty occupation: «Dentistry» / O. V. Denga. – K., 2001. – 32 pages.

06. Anisimov M. V. Caries and pulpitis treatment efficiency depending on anesthesia method in patients with
burdened allergic history / M. V. Anisimov // Dentistry messenger. – 2011. – N°4.

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Case Studies 04_Mise en page 1 25/02/13 12:11 Page21

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