Over last few decades restorative dentistry could be termed, “The Era of Resin”.  As practitioners, we all know the wonderful upsides of these materials, but equally so, they have their limitations.  Over recent years, new chemistries have been launched into dentistry and one such product is Doxa’s Ceramir cement and amazingly, it has been five years since the Catapult Group was asked to evaluate this cement.

5 years later

There is always a nervousness when evaluating a new cement, because let’s face it, if the cement fails, so does the restoration.  Thus, when this small Swedish company contacted us about this new calcium alumina cement, there was definitely some hesitation.  Now, 5 years later, we can openly say, Ceramir has well proven itself as a universal cement for many of our evaluators. 

First, let’s understand that all resin cements have micro-leakage and little if any ability to inhibit plaque and caries.  They continue to improve in-regards to ease of use and offer excellent retention along with wonderful physical properties of flexural and comprehensive strengths.  So, the question, is this enough? 

Ceramir’s chemistry offers the clinician a cement first off that is biocompatible.  Openly, this is my implant cement of choice and given the new liquid/powder mix formulation, implant cementation has never been easier.  The fact that it is biocompatible, radio-opaque, has good retentiveness and its thin, allows me to minimize potential excess cement issues in implant crown delivery.

Studies¹ in vitro have shown the potential ability to remineralize dentin at the marginal gap interface and this is all based on the calcium release along with the cement’s alkaline chemistry and unique formulation.  With over 5 years in use in my office, I have had to remove some fractured porcelain to zirconia crowns and crowns that contacts have opened post insertion.  I know this never happens to any of you,(😊) but here is what I can state, in all of these crowns, there were no signs of staining at the margins nor any signs of recurrent decay.  Additional related features include; zero shrinkage upon setting and low solubility, only adds to the wonderful qualities in this cement. The fact that this cement is moisture tolerate and thus is a non-issue in subgingival situations or in clinical situations where ideal isolation is often very challenging, this cement provides such additional advantages.

Clinically, this is the most comfortable cement for the patient.  I rarely anesthetize the patient and routinely, the patient looks at me as if to comment, “that’s it” after the crown is placed.  The product has been updated in its trituration delivery with a new capsule system that makes the mixing technique so simple, simply triturate for 8 seconds and load the crown.  Yes, liquid/powder mix is now available for those of you who no longer use triturators and is ideal for implants because you don’t need the quantity in a single capsule.

Additional advantages of this cement include the fact that primers and silanes are contraindicated on the internal side of ceramic restorations.  This not only lowers the cost of delivery, it simplifies the process, simply clean and place.  Clean up is beyond simple because at the 3- minute mark the cement begins to gel, and given its white opaque appearance, you simply can’t miss!  At the 5-minute mark the cement has set fully enough to allow the patient to be dismissed.

How it works

The new chemistry found in Ceramir truly could make this a game changing product in the cement category, so it’s important to understand how it works. The material hardens through a mechanism of dissolution and reprecipitation, where nano-crystals are built and bonded to each other. When this happens, Ceramir seals at the tooth’s interface, further building hydroxyapatite in proximity of the dentin interface—making the material bioactive.

Once the capsule is triturated, the dissolution of water causes a reprecipitation. Nanometer-sized particles are built and bond upon each other at a basic pH. As the material dissolves, it wets the tooth, and when the nano-crystals start to form, they precipitate on the tooth surface and upon other crystals.

After only a few minutes, the hardening mechanism seals the interface and creates the conditions needed to build hydroxyapatite at the interface. In essence, it’s adhesion to the tooth takes the same form as its infrastructure. 

There’s another important factor in play here. Once the powder is dissolved, hydroxide ions are released to create a basic pH. This higher pH is critical. It creates an environment conducive to growing and stabilizing the hydroxyapatite, making it caries resistant long term.

Limitations

Veneers and restorations that are specifically adhesion based for support are contraindicated.  Additionally, I have found poor retentive preparations are best resin bonded for additional retention.  Lastly, for preparations that are have the majority of the preparation comprised of a composite core, I prefer resin cements.

Given the challenges we face as clinicians, the biomimetics and additional features of Ceramir, truly place this product in a unique category in dentistry.  Now 5 years in our clinical practice and thousands of crowns placed, this product continues to deserve the Catapult Vote of Confidence.

References

1.  Jefferies, S. R., Pameijer, C. H., Appleby, D. C., Boston, D., Galbraith, C., Lööf, J. and Glantz, P.-O. (2012), Prospective Observation of a New Bioactive Luting Cement: 2-Year Follow-Up. Journal of Prosthodontics, 21: 33–41.

Clinical Case

This patient presented with a recently placed (less than 2 years) crown that had been symptomatic since placement.  Poor margins were noted on the x-rays and the crown was treatment planned to be remade and evaluate the symptoms while temporized.  After 3 weeks in a temporary crown, the patient was symptom free and final delivery was complete. The crown was cleaned with Ivoclean for 20 seconds and then rinsed and dried.  The tooth was cleansed with Cavity Cleanser (2% Chlorhexidine) and left mildly moist prior to crown placement.

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 Picture 1 The Zirconia Crown with customized staining

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Picture 2 Crown preparation with subgingival margins

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Picture 3 Placement of Ceramir into the crown

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Picture 4 Placement and notice the white opaqueness of the cement and the 360° extrusion of the cement at the marginal interface

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Picture 6 Immediately after cement clean-up