Journal Club

Pediatric Dentistry Vol. 32; No. 7; Nov – Dec 2010

Presented By,
Dr.Mandeep Rallan,
Junior resident III
Nano-ionomer Tooth Repair
in Pediatric Dentistry
Constance Marie Killian, Theodore P. Croll
• Restoration of primary teeth has undergone a renaissance in the last
15 years. The development of resin – modified glass ionomer
restorative cements (RMGICs) has provided tooth colored materials
that have all the benefits of the glass polyakenoate (glass ionomer)
systems, including: chemical adhesion to tooth structure; fluoride ion
release and incorporation into similar to that of tooth structure. These
benefits were in addition to the advantages of resin based composite
(RBC) materials, including: wear resistance; fracture toughness;
fracture resistance; and better esthetics.

Introduction
• The addition of photosensitive resin to the glass ionomer formula
allows the dentist to control the initial hardening reaction by using
intense blue light beam exposure. In addition, the resin component
improves the set material’s physical properties.
• Examples of RMGICs include Photac – fil (3M ESPE, St. Paul, Minn), Fuji
II – LC (GC America, Alsip, III), and Vitremer (3M ESPE). In research
reports and clinical reports, these materials have demonstrated their ability
to perform well under the rigorous conditions existing in the oral cavity. To
date, however, they have not been able to match some of RBC’s properties,
such as cohesive strength, resistance to wear, and esthetics.

• It is clear that dentists would benefit from and appreciate having a single
dental material that incorporates the advantages of both hydrophilic
RMGICs and hydrophobic RBCs, while eliminating the disadvantages of
each.
• Such a material would: chemically adhere to enamel and dentin,
therapeutically reducing the solubility of the tooth to acid challenge; have an
antibacterial effect due to fluoride interaction; have a coefficient of thermal
expansion similar to that of tooth structure, rendering the set material stable
and more resistant to marginal deterioration and microleakage; not shrink or
expand during the hardening reaction; have high resistance to wear via
occlusal forces and mastication or erosion by chemical influences in the
mouth; have high cohesive strength and resistance to initial fractures and
propagation of fractures; and be tooth – colored, highly polishable, and easy to
handle, including a mechanism for rapid “on – demand” hardening (as with
photo-polymerization)
• In 2007, a new generation of RMGICs was introduced. Ketac Nano
(3M ESPE) is described by the manufacturers as a “nano-ionomer”.
Incorporation of nano-technology into this material enhances
physical properties, most notably resistance to wear and
polishability/esthetics. Ketac Nano combines nano-filler and nano-
filler cluster with fluoro-alumino silicate glass particles in such a
way that there are improved color characteristics and better
polishability.
• Unlike Vitremer (3M-ESPE), which is supplied in a powder-liquid
format, Ketac Nano is stored and delivered as a 2 - paste system in a
unique, double-barreled clicker-dispenser (3M-ESPE). This method
of delivery greatly simplifies handling of the material and eliminates
some of the problems associated with powder particles left
unincorporated into the final blend.
• The purpose of this study is to describe the nano-ionomer and its
indications for use in pediatric and adolescent patients. The
technique of application is described and clinical cases are presented
to document the clinical experiences with the filling material.
• The manufacturer’s technical product profile describes Ketac Nano as
follows: -
• “Paste A is resin-based and contains fluoro-alumino silicate glass, silane –
treated silica and zirconia silica nano-fillers, methacrylate and dimethaacrylate
resins, and photoinitiators.”
• “Paste B is water based and contains polyalkenoic acid copolymer (Vitrebond
Copolymer, 3M ESPE), silane treated zirconia silica nano-clusters, silane
treated silica nanofiller, and hydroxymethylmethacrylate (HEMA). Ketac Nano
Primer contains water, HEMA, polyalkenoic acid copolymer, and photo-
initiators.”
• According to the manufacturer’s technical product profile for Ketac
Nano, virtually all physical properties of Ketac Nano exceed those of
other popular RMGIC restoratives. The manufacturer reports that the
nano-filler (5-25 mm) and the nano-filler clusters (1-1.6 mm) are “
loosely bound agglomerates of nano-sized zirconia/silica,” that
comprise approximately 60% of the glass component of Ketac Nano
and are responsible for higher filling content and accompanying
enhancements in physical properties.
• Additionally, according to the manufacturer, this material has better
polishability that other RMGIC restorative cements and fluoride ion
dynamics comparable to other glass ionomers. The manufacturer’s
technical profile also states that in vitro tests have shown that Ketac
Nano has the ability to act as a fluoride reservoir and recharge the
fluoride release after application of a topical fluoride source.
• Because of the unique restorative challenges associated wit the
patient population they treat, pediatric dentists can find many
applications for RMGIC restoratives – especially nano – ionomers.
Pre-cooperative or uncooperative children, including those with
special health care needs, cooperative children with multiple caries
lesions, adolescents with high caries susceptibility, children or
adolescents with sensitive hypoplastic/carious permanent molars that
are partially erupted, all can be reliably treated with Ketac Nano.
• The author’s experience confirms the manufactirer’s indications for
the use of Ketac Nano in the following cases: -
• Primary teeth –
• Class I, II, III and V restorations,
• Interim therapeutic restorations

• Permanent teeth –
• Small Class I, III, and V restorations,
• Transitional restorations,
• Sandwich (stratification beneath bonded RBC) technique.
Clinical Technique: -
• Tooth presentation can generally follow traditional outline forms for repair
using silver amalgam. There is no need to cut sharp internal line angles,
however, or extend preparations into :toothbrush – access cleansable area.”
In addition, associated pits and fissures that are not carious need not be cut
for “extension for prevention.” Such regions can be debrided with very
small round burs and sealed with traditional resin bonding, adjunct6ively.
Mechanical interlocking retention form usually accompanies debridement
of carious substance, and such design is useful for maximum retension of a
chemically bonded nano-ionomer. Once tooth preparation is complete,
Ketac Nano is usee in the following manner: -

Methods
1. Ketac nano Primer is painted in the cavity preparation, covering the
cavosurface margins. Care must be excised to ensure that the primer
thoroughly wets the preparation to allow for intimate chemical contact
at the tooth/cement interface as the displaced with a light stream of air
or blotted with a dry microbrush.

2. The curing light beam is applied to the tooth for 10 seconds.

3. The material is “clicked” out onto a mixing pad and blended rapidly
with a cement spatula. Thorough spatulation for approximately 20
seconds is necessary for complete blending of the components
4. The cement is then scraped into a thin lumen Accu-Dose orange
syringe tip (Centrix, Inc, Shelton, Conn). At this point, it is helpful
to leave the material in the syringe tip for 30 to 40 seconds. This
delay allows the material within the preparation and decreases
stickiness.

5. The material is injected slowly into the internal aspects of the

preparation, taking care to avoid trapping air bubbles.
6. Based on the manufacturer’s recommendation, increments no
thicker than 2 mm should be placed and light cured individually.
Other RMGICs have 3 hardening reactions: -
• Photocuring.
• Chemical resin curing.

• The glass ionomer acid base reaction.

Ketac Nano does not have a chemical resin curing component, so it

is critical that complete light beam saturation occurs.
7. Ketac Nano should be placed incrementally, and ultimately overfill
the preparation, with the last layer being compressed on the tooth
surface – ensuring complete coverage and fill at the margins. For
this purpose, the authors use a large ball burnisher for occlusal
restorations and a wide flat instrument in Ketac Nano Primer helps
prevent it from sticking to the material
• Trimming, finishing, and polishing can be completed with slow –
speed medium and fine diamond burs, aluminum oxide or diamond
finishing strips, and discs in the same way one would complete an
RBC tooth repair. In some cases, after finishing the restoration, the
authors have sealed the treated surface using self etching bonding
agent and clear resin sealant.
 Case Examples: -
• Examples of the following are demonstrated in the following figures: -

Figure 1: - Primary Tooth Class II Restoration

Results
Figure 2: - Primary tooth Class I restoration
Figure 3: - Primary Tooth Interim Therapeutic Restoration (ART)
Or Class III Restoration
Figure 4 & 6: - Permanent Tooth Class V Restoration Adolescent
Figure 5: - Permanent Tooth Transitional Restoration for a Hypoplastic Molar

Figure 7: - Permanent Tooth Interim Therapeutic Restoration

• After using the nano - ionomer frequently and routinely in our pediatric dentistry
practices, from January 2006 until the time of this writing (August 2009), we are able to
make the following observations: recurrent caries at cavosurface margins has not been
observed; cavosurface wear or erosion , as evidenced by “ledging” at margins, has not
been observed; there have been no reports of immediate or long – term post operative tooth
sensitivity; injection of the material into the cavity preparation should be accomplished
using the Accu – Dose Syringe Tip (Centrix, Inc, Shelton, Conn) of the smallest lumen size
- delayed injection for approximately 30 seconds, after mixing, allows for some
congealing of the material and makes for better handling; polishing hardened nano –
ionomer material can be achieved using identical methods that one would use for RBC’s;
because there is no chemical resin hardening reaction in Ketac Nano, care should be taken
that the light curing reaction is penetrating and complete so that the material achieves its
full mechanical properties; treatment can usually be accomplished faster than with silver
amalgam or RBC, once the dentist has become experienced with the nano – ionomer.
• Restoring the dentition of a pediatric patient presents several
challenges. The patient population often has a limited ability to
cooperate and tolerate extensive procedures due to age,
temperament, or special health care needs. In addition, the early
permanent dentition is unique in that certain developmental dental
defects present when the teeth are only partially erupted, making
such teeth difficult to isolate and restore.

Discussion
• RMGICs have been shown to be a suitable definitve restoration for
primary molars. Because of the improved physical properties of
Ketac Nano, this nano – ionomer, as compared to RMGICs without
nano – fillers, should perform well in the long term. As time passes,
in vitro comparison of Ketac Nano with RBC, as enamel replacement
restorative materials, will be important to the clinical dentist.
• For restoring permanent teeth, the glass ionomer/resin bonded
composite stratification technique has been documented and
advocated. This technique also has been termed “sandwiching” or
“layering”.
• In such cases, properties of light – hardened glass ionomer cements
(GICs) make them an ideal dentin replacement material; the properties
of RBCs make them ideal enamel replacement.
• When used together to restore a permanent tooth, the properties of
each material are maximized and the resulting restoration simulates
the tooth’s form and function.
• When call this “tissue – specific direct tooth repair”. For example, in
the case of a hypoplastic (carious or not) permanent molar that is
partially erupted, materials such as Ketac Nano provide a
hydrophilic, adhesively bonded transitional restoration that replaces
both dentin and enamel.
• Year later, when the tooth is fully erupted, if wear is evident, the
restoration can be resurfaced by simply reducing some of the
RMGIC surface and bonding a new RBC layer. In such a case, the
pulp ahas been protected and is less traumatized than it would be if
the entire RMGIC mass were to be removed.
• Glass Ionomer Cements are especially advantageous in treating individuals
who are at high risk for caries. Because these materials contain
transferable ions, they can be considered “therapeutic”.
• The fluoride ions present in glass ionomer systems release fluoride to
associated enamel and dentin over a considerable period of time (at least 5
years) and the resulting tooth structure is less susceptible to acid challenge.
In addition, the water – based nature of the materials allows it to serve as a
fluoride reservoir, taking up fluoride from dentifrices, rinses, and topical
fluoride solutions.
• This property makes the GICs superior to hydrophobic RBCs for high
caries – risk patients. An additional benefit is that a glass ionomer/dentin
chemical bond does not hydrolyze over time.
• When used as an interim therapeutic restoration for primary teeth _ie, in
the restoration of incipient early childhood caries), Ketac Nano is
functional and esthetic. Because it contains water and hydrophilic
components (methacrylate functional polyacrylic acid and water miscible
polymerizable monomers) its placement is less sensitive to total moisture
control than is an RBC. Such restorations are typically placed after gross
caries removal, and a series of regimented applications of topical fluoride
varnish is provided over a period of months.
• This procedure often can defer more complex treatment that could require
sedation or general anesthesia, which have associated risks and higher
costs.
• Ketac Nano is the latest generation of a family of materials that has
demonstrated its usefulness in restorative dentistry. Its improved
physical properties and handling characteristics make the nano –
ionomer especially useful for all dentists who treat children.
• As years go by, further studies, including controlled clinical trials, will
be important to affirm the role of this material in restorative and
preventive dentistry. Clinicians also are eagerly awaiting future
improvements in adhesively bonded direct application restorative
materials that will incorporate into one substance all the advantages of
glass ionomer systems and resin – based composites.

Conclusions
 Treatment of Mucocele of the
Lower Lip With Diode Laser in
Pediatric Patients: Presentation of
2 Clinical Cases
Irineu Gregnanin Pedron, Vivian Cunha Galletta, Luciane Hiramatsu
Azevedo, Luciana Correa
• The term “mucocele” is used to define the accumulation of mucus secreted
from salivary glands and their ducts in the oral cavity’s sub-epithelial tissue.
• Clinically, a mucocele is characterized be an increase in volume, with a
bubble-like shape that contains saliva, and is similarly colored to that of the
normal mucosa or it may present blue coloration, depending on whether it is
deep or superficial, respectively.
• Such lesions may occur in any region of the oral mucosa, but are mainly on
the lower lip’s inner surface, buccal mucosa, and tongue’s ventral surface. The
diagnosis may be used on clinical characteristics, history and evolution, and
histopathological examination.

Introduction
• The principle etiology of a mucocele is mechanical trauma, causing the
rupture of a salivary duct and consequent mucus extravasation within
the surrounding tissue. A second mechanism for mucus accumulation is
obstruction or narrowing of the salivary duct walls, causing ductal
expansion. In this case the lesion is named as mucus retention cyst,
being considered a true cyst because of the presence of a cavity with
epithelial lining. When major salivary glands of the oral floor are
involved, the lesion is named ranula.
• Mucoceles are among the most common biopsied oral lesion in
pediatric patients in various countries, including Brazil, Argentina,
Taiwan, Thailand, Turkey, Greek, the United Kingdom and the United
States.
• Treatment options for mucoceles include surgical excision,
marsupialization, micro-marsupialization, cryosurgery, laser
vaporization, and laser excision.
• Management of a mucocele in children can be complicated by
occasional behavior problems during treatment. With the advent of
high-intensity lasers, this type of lesion may be treated efficiently due to
its prompt hemostasis and no need to suture, which reduces surgical
time and reduces wound infection.
• A 9 year old boy sought treatment at the stomatology clinic of School
Of Dentistry, University Of Sao Paulo, Brazil, complaining of a
swelling on the lower lip mucosa. Clinically, the patient presented an
asymptomatic increase in labial volume, measuring approximately 2
cm that episodically changed in size but remained normally colored.

Case Reports
• The patient had reported an acute trauma 1 month before sustained while
playing sports, when his lower lip was pressed against the fixed
orthodontic appliance. The orthodontic brackets were remover after the
incident to avoid further trauma.

• Additionally, a 10 year old boy was referred to the stomatology clinic of

School Of Dentistry, University Of Sao Paulo, Brazil, presenting a
painless translucent nodule on the lower lip mucosa near the left
commissure and approximately 1 cm in size and, of 1 – year duration.
The lesion had been increasing in size for 2 days.
• Based on the clinical characteristics and history, mucocele was the
initial clinical diagnosis for both lesions. Removal on the lesions was
performed under local infiltrative anesthesia using a diode laser at
continuous mode in a contact technique with a power setting of 2 W.

• Dissection was performed, separating the lesion and its associated

minor salivary gland from the adjacent tissue.

Management
• Postoperative care included 0.15% benzidamine hydrochloride
mouthwash 3 times per day for 1 week, and the patients were advised
not to bite their lower lips to avoid recurrence of the lesion. For the
patient with the orthodontic appliance, wax was placed over the
brackets to protect the wound.
• Both patients were followed until complete healing was achieved,
which occurred in 30 days.

• The patients have been under observation for 12 months and have
not shown signs of recurrence.
• The removed lesions were analyzed at the Surgical Pathology Laboratory
of the School of dentistry, University of Sao Paulo, Sao Paulo, Brazil.
Extravasation mucocele was confirmed by the presence of mucus in the
lamina propria, which was surrounded by inflammatory cells and an
immature granulation tissue.
• A minor salivary gland with normal characteristics was also observed in
one of the specimens. In the border of the 2 biopsies, a discrete collagen
denaturation compatible with the laser’s thermal effects was present. The
extent of this tissue alteration was minimal and did not interfere with
microscopic analysis.
• Several techniques have been proposed for the treatment of a mucocele,

such as cryosurgery, micromarsupialization, and marsupialization. The

most common treatment, however, is complete removal of the lesion and

the salivary gland involved via surgical excision.

• Marsupialization had resulted in considerably higher recurrence rates.

Micromarsupialization had been suggested to have lower recurrence rates,

although it was restricted to lesions with clinical characteristics that

strongly suggested a diagnosis of mucocele, since histopathological

examination was not possible.

Discussion
• Cryosurgery yielded satisfactory results with no recurrence.
Reported postoperative symptoms, however, included marked edema
and irritation, as well as a prolonged healing time.
• Vaporization with argon and Nd:YAG lasers has been described for
the treatment of mucoceles. Both lasers procedures presented
satisfactory results with low recurrence rates and were well tolerated
by the patients, whose discomfort was the main complaint reported.
• The diode laser (wavelength 800 – 810 nm), similarly to argon and
Nd : YAG lasers, is intensely absorbed by hemoglobin, elevating the
temperature and promoting coagulation and carbonization of the soft
tissues, such as the oral mucosa.
• Removal of mucoceles with the diode laser was effective in the 2
cases presented, resulting in minimal discomfort and scarring. Due to
reduced bleeding and the short operative time Vs the conventional
surgery method, it may be especially suitable for children and less
cooperative patients.
• Regardless of the treatment approach, total excision of lesions and
follow-up is necessary due to the high recurrence rate of mucoceles.
Excision of mucoceles with a diode laser permits complete removal
of the lesion along with any minor salivary gland involved and its
histopathological examination, which is highly recommended for
sited with high frequency of salivary gland neoplasias, such as the
palate and the buccal mucosa.
• Treatment of mucoceles with a high intensity diode laser provided
satisfactory results in the 2 cases presented. As the incidence of
mucoceles in children is relatively high, this technique may represent an
improvement over other techniques and an adequate protocol for this
lesion in a pediatric population. Appropriate power-set parameters must
be considered for this type of procedure to avoid excessive thermal
damage to the soft tissues and consequent unfavorable postoperative
symptoms.