Given the criteria Lou uses to evaluate new dental products, Ceramir cement by Doxa is a "game changer" that outperforms other cements. It provides a long-lasting, permanent seal that inhibits caries and plaque, has no microleakage or shrinkage, and is biocompatible and easy to use. Lou has cemented over 2000 crowns with Ceramir and found it superior to other cements due to its ability to create hydroxyapatite crystals, thin film thickness, and simple 4-step application process. Ceramir also allows for easier removal of cemented crowns if needed in the future compared to resin cements.

1. GameChangers
BY LOU
GRAHAM
DDS
For more about
Lou, see his
full bio on page 4
As a reviewer for the Catapult Group, each year
we evaluate 15 or more new products that are
coming into our dental market and like you,
I ask myself the essential questions:
Does this product ultimately deliver a better
result than one I am currently using?
Does this product add time to the procedure,
or is it more efficient in its use?
In the same regard, I ask myself, is it easy to use
or so challenging that I won’t want to use it?
Is the product more expensive and if so,
is it worth it?
Is this product beneficial to my patient
and in what manner?
BUSINESS & PRACTICE DEVELOPMENT

2. SPRING 2014 | TheProDentist.com
temporary cement on vital teeth which
we all know can be very uncomfortable.
The cement is antimicrobial and provides
excellent retention. If you are currently
using a temporary cement that does the
above, don’t change, but if not, enjoy the
change.
Thus the 15 minute appointment
starts with relative easy removal of the
temporary crown, no anesthetic, minor
adjustments and then we are ready for
the final cementation. The next step is
to rinse the crown internally out with
water and then simply place Ivoclean
from Ivoclar into the crown for 20
seconds and rinse away followed by air
drying (Doxa has shown that Ivoclean
is not required prior to usage with
Ceramir cement). This cleanses the
internal surface and prepares the internal
surface to be cemented. This works for
all different types of crowns, dilithium
silicates, zirconia and metal. This again
is a technique that satisfies my critieria
of change: easy, cost effective, long term
better cement internal surface adaptation
to the crown.
The final step without question is to
cement a crown and that cement should
have the following properties:
• Long term permanent seal
• Internally can create new apatite
crystals as it integrates with dentin
• Inhibit caries
• Inhibit plaque
• No micro-leakage
• Moisture tolerant
• No shrinkage
• Biocompatible both internally and
externally
• Low solubility
• Strong physical properties such as
flexural and compressive strengths
• Thin film thickness
• Universal usage for all ceramic
crowns, metal crowns and
implants
• Good working and setting times
both for single and multiple units
• Superior retention
• Comfortable with minimum
sensitivity
• Easy Cleanup
• Long term studies
As you look up at the above, the vast
majority of cements cannot fulfill the
above criteria and Ceramir cement by
Doxa performs with each of the above
requirements. With over 300 crowns
cemented in my own practice and well
over 2000 in the Catapult Group in just
the past 2 plus years, the cement stands
out with all of the above characteristics.
The process involves the dissolution
of powder after the activation of the
capsule and trituration causing a
re-precipitation where particles in
nanometer sizes are built and bond upon
each other at a basic pH. As the material
dissolves it wets the tooth (hydrophilic,
keep the preparation moist if possible)
and then as the nano-crystals begin
to form they precipitate on the tooth
surface and upon other crystals. Within
minutes the hardening mechanism
begins creating a dual functional result:
sealing the interface and creating the
conditions necessary at the interface of
building hydroxyapatite. In essence, it’s
Clinical efficiency can be no better
explained than what I term the crown
delivery appointment. Doctors range
from 15-45 minutes for the delivery of
their laboratory crowns and the question,
why such a variation? A quality lab,
should deliver a restoration (based on a
good preparation and impression) to the
office requiring very few adjustments.
Such adjustments are made if required
at the contact areas and occlusally.
The usage of articulating paper both
interproximally and occlusally allows
the practitioner to adjust specific areas
and then once adjusted and polished,
the crown is ready for delivery. Sounds
simple but all too often the process
becomes far more complicated and time
consuming because of the cements and
various other adjunctive treatments we
utilize both for temporization and final
cementation.
LET’S WALK THROUGH
THE APPOINTMENT AND YOU
WILL SEE WHY I HAVE TWO
VERY DIFFERENT CEMENTS.
For your everyday temporaries, my
recommendation for usage is Cling²
by Clinicians Choice. I was introduced
to this cement two years ago when
the Catapult Group reviewed the
product and these are the reasons I
have incorporated this into my clinical
techniques. The cement comes out with
the temporary, and does not stick to
natural tooth. The only time it sticks to
the tooth is too a bonded buildup which
is easily is removed from the build-up.
The beauty of this, the patient does not
have to be numb rarely for removal of
Given those questions, few products that I see every year are what I term “game changers”. Doxa’s Ceramir cement
is a game changer and answers all of the above questions with a definite YES. Cementation ultimately is one of the
most critical procedures we perform almost every day in our practices and truth be told, we all require a product
that delivers the ideal seal from acid attacks, bacteria, moisture, heat, and the associated challenges that occur
every day in the oral cavity because a crown’s margin is truly only as good as the cement. Yes, accuracy matters,
but again, you can have the best margins, but without the ideal cement, those margins eventually break down. This
article will touch both on the uniqueness of the chemistry and the clinical procedures involved with this cement.

3. 10
adhesion to the tooth takes the same
form as its infrastructure. Another
important feature of this cement is
that when the powder is dissolved,
hydroxide ions are released, created a
basic pH. This higher pH is critical on
many fronts because it not only creates
an environment conducive to growing
hydroxyapatite but also stabilizes the
hydroxyapatite (hydroxyapatite breaks
down with acid). Long term, this means
it’s caries resistant, i.e. to acid attacks.
Doxa has now published 2 year data
and has 3 year data confirming: no
loss of retention, no secondary caries,
no marginal discolorations, and no
subjective sensitivity. There are no longer
term studies are available from Sweden.
With all this said, let’s bring this
down to earth and truly explain how
this may be the game changer in the
cement category. Once the internal
surfaces of: all zirconia crowns, zirconia
to porcelain, gold, porcelain fused to
metal and lithium disilicate (prepared
via the guidelines of eMax) crowns are
all cleaned in the proper way (described
earlier), this cement can be used for all of
the above without any silanes or primers.
This avoids unnecessary materials,
potential mistakes and in fact makes the
process far more universal and simplified.
Ceramir makes an ideal universal
posterior cement with exceptions: These
include: ceramic inlays/ onlays, and
underprepared e Max crowns which
required adhesive cements to support the
thin dilithium silicate crown. This author
has also used this material for anterior
restorations fabricated out of: zirconia
to porcelain, e Max and porcelain to
metal restorations. The exceptions in
the anterior category would be veneers,
Empress ,feldspathic crowns and any
ceramic crown that is thin (the white
will shine through and these minimal
preparation crowns require adhesive
resin cements for further support
internally.
The beauty of this cement, after
placing it into the mouth and waiting 3
minutes, cleanup is as easy as any resin-
ionmer cement. Seating multiple crowns
(all at once) is equally easy and the
capsules come in single dose and multiple
dose (up to 3 crowns). Another quality
thus far not discussed is the thickness.
It’s very thin, 15 microns and makes for a
wonderful implant cement because it is
tissue biocompatible which becomes very
important in that peri-implantitis is often
the result of excess cement that is NOT
biocompatible.
THE CEMENTATION PROCESS:
The cement is hydrophilic so
routinely once I am ready to cement,
I soak the preparation for 60 seconds
in 2% chlorhexidine for final cleansing
(Cavity Conditioner by Bisco) and then
rinse or blot with wet gauze and leave the
preparation mildly moist. This is all being
done while my assistant follows the 4
step protocol for the cement.
STEP 1
Place the capsule in an activator
that comes with the kit, and
press down for 3 seconds
STEP 2
Triturate for 5 seconds a single
dose or 8 seconds a multi dose
STEP 3
Remove the capsule from the
triturator, rotate the nozzle of the
capsule and then place it is
dispensing instrument that also
comes with the kit
STEP 4
Dispense the material
into the crown.
A working time of 2 minutes allows
you to seat multiple crowns if required,
and clean up begins no later than 3
minutes. Removal of the cement is
similar to that of a resin-ionomer
cement, with no light curing. So at the
3 minute mark you remove the excess
cement, floss down and wait the full 5
minutes for final flossing and say bye-bye.
Helpful hints include: verify cement
extrusion 360 degrees from the crown
as it is seated, if not, simply remove the
crown, add more material and reinsert,
remove excess cement on the soft tissue
not related to the margins, this can be
in the vicinity and prior to setting, the
cement is very easy to remove.
Sensitivity is virtually non-existent
and again another benefit to the patient,
comfort and no anesthesia required.
Another key issue, that is not routinely
discussed relates to what happens when
these all ceramic crowns in the future
require removal? As many of you have
experienced, removed resin cemented
ceramic crowns, especially those in
the posterior require far more time
because the cement often masks natural
tooth structure and all too often we
can’t simply remove the crown without
sacrificing tooth structure. These crowns
often cannot be just sectioned off in two
pieces like PFM’s and this equally adds
to time and stress for the practitioner.
With Ceramir, I have had to remove 2
crowns cemented with this material
due to drifting and hence open contacts
(don’t you love those). When sectioning
through the crowns, one can see the
white opaque cement which is such a
positive! Yes, the cement has excellent
retention, and removal was more than
a simple slice, but both were far simpler
than resin cemented restorations.
In summary, Ceramir cement with
its biomimetic properties sets itself
apart from other current cements
on the market. This simplified 4 step
activation- insertion procedure allows
everyday cementation to be delivered in a
symptom free manner with usage for the
vast majority of anterior and posterior
crown restorations in our practice.
To review clinical cases, please visit Doxa’s Learning Center at
www.catapultuniversity.com