Bioactive Materials for

Pediatric Dentistry
About five years ago, while perusing the Dentaltown message
boards, I saw a discussion thread about a new restorative
material called ACTIVA BioACTIVE. I ordered a Starter Kit and
began to dabble. Several months later, I received an invitation
from Dentaltown to visit Pulpdent, the Boston-area dental
manufacturer that developed ACTIVA. What I learned during
that visit fundamentally changed the way I practice dentistry.

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I run a pediatric practice and common cases include
cracked composites with recurrent decay and washed
out glass ionomers, some of which had to be replaced
up to three times before a primary tooth exfoliated.
Appointments for replacement restorations are time-
consuming and expensive, not to mention inconvenient
for my patients and their families.

Bioactive restorative materials, like ACTIVA, offered

an alternative to brittle composites and soluble GIs.
They also made clinical procedures more efficient.
The material’s dual cure technology ensured depth of About the Author
cure while the dynamic ion exchange helped achieve
true marginal integrity. I began to use bioactive and
biomimetic materials more extensively on fractured
anterior teeth, Class II restorations for primary and
permanent teeth, and Class V restorations. The
restorations looked excellent at recall, with radiographs
showing much less recurrent decay than traditional
inert materials.

My office now stocks fewer restorative materials, Dr. Josh Wren practices
saving my practice both time and money. I have pediatric dentistry in
replaced my traditional composites with ACTIVA,
Brandon, Mississippi. He
which has simplified our operatory protocols
is the founder of Pediatric
significantly. Having one restorative material with one
Dental Seminars, which
protocol reduces the possibility of error and the need
for expensive re-treatment. serves to educate general
dentists on topics related to
The following four cases are examples of the many pediatric dentistry through
ways I use ACTIVA BioACTIVE in my practice, ranging
lecture-based seminars and
from everyday Class II restorations and diastemas to
hands-on workshops.
treatments for hypocalcified molars. The possibilities
for bioactive and biomimetic restorative materials like
ACTIVA BioACTIVE are endless, and I hope these cases
spark your curiosity and creativity.

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Case 1: Pulpotomy Followed by Direct Restoration
I always review a variety of treatment options
with patients and their families before obtaining
informed consent. In the following case, I had
recommended a stainless steel crown, but the
patient’s parent opted for a direct composite
restoration instead. The patient was a four-year-
old boy with distal occlusal decay in tooth #S
(Figure 1) along with signs of reversible pulpitis.
The pre-operative offset bitewing showed
extensive decay (Figure 2). I placed an Isolite
and removed the decay, which resulted in a
pulpal exposure at the disto-buccal pulp horn.
(Figure 3).

I decided to complete the restoration Figure 1. Shows disto-occlusal decay in tooth #S.
before undertaking the pulpotomy to avoid
contamination from the ginvigal sulcus. After
placing a sectional T-band matrix and Garrison
A+ wedge, the distal occlusal lesion was restored
using ACTIVA BioACTIVE-RESTORATIVE (Figure 4).

The pulpotomy was then completed with sterile

6 and 2 round burs. Pressure hemostasis was
achieved with a cotton pellet pressed against Figure 2. Pre-operative offset bitewing showing extensive
decay.
the pulp stumps for 20-30 seconds. Figures 5
and 6 show the completed pulpotomy.

Following the pulpotomy, I placed a 2-3 mm

layer of Biodentine (Figure 7) on the pulp stumps
(Neo-MTA could also have been used). Rather
than waiting for the Biodentine to completely
set before removing excess material on the axial
walls, I placed a 2 mm layer of ACTIVA BioACTIVE- Figure 3. Shows tooth #S after decay removal and
preparation. There was pulpal exposure during decay
BASE/LINER and light cured for 5 seconds using
removal, which is not shown in the figure above.
the VALO light (Ultradent). Having sealed off the
Biodentine, I could clean the axial walls of the

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preparation and immediately restore the tooth.
I applied the VivaPen (Ivoclar) bonding agent
and used ACTIVA BioACTIVE-RESTORATIVE to
complete the restoration (Figure 8). Both the
6-month and 26-month post-operative bitewings
show excellent results (Figures 9 and 10).

Figure 7. A 2-3 mm layer of Biodentine was placed over

the pulp stumps followed by a 2 mm layer of ACTIVA
BioACTIVE-BASE/LINER.

Figure 4: After placing a sectional T-band matrix and

Garrison A+ wedge, the disto-occlusal lesion was restored
using ACTIVA BioACTIVE-RESTORATIVE. The restoration
was placed before the pulpotomy in order to wall off the
pulp from oral contaminants. Figure 8. Shows final restoration with ACTIVA BioACTIVE-
RESTORATIVE. The margins were finished and polished
after the final restoration was placed.

Figure 5. The pulpotomy was completed with sterile 6

and 2 round burs. Pressure hemostasis was achieved
with a cotton pellet pressed against the pulp stumps
for 20-30 seconds. Notice the Activa barrier (dam) Figure 9. Shows the 6-month post-operative offset
preventing contamination of the pulp chamber. bitewing.

Figure 6. Shows completed pulpotomy. Figure 10. Shows the 26-month post-operative bitewing.

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Case 2: Repairing a Failing Class II Restoration
An 8-year-old patient came to my office with a
failing occlusal lingual composite (Figure 11) in
the upper right second primary molar (tooth
#A). I recommended a full coverage restoration,
but after reviewing several treatment options,
the patient’s primary caregiver requested an
esthetic, bonded direct restoration.

The recurrent decay was excavated from Tooth

#A, leaving affected dentin over the pulp to
avoid pulpal exposure (Figure 12). The tooth
was asymptomatic at this point. After a total
Figure 12. The infected dentin was removed and affected
etch treatment with Gel Etchant (Kerr) and dentin was left in place to avoid pulpal exposure.

application of the VivaPen (Ivoclar) bonding

agent, a 1-2 mm layer of ACTIVA BioACTIVE-
RESTORATIVE was placed and cured for 5
seconds with the VALO curing light (Ultradent)
(Figure 13). The remainder of the preparation
was bulk filled with ACTIVA BioACTIVE-
RESTORATIVE (Figure 14). After curing, the
restoration was finished and polished.
Figure 13. After a total etch treatment with Gel Etchant
I felt confident that ACTIVA’s esthetics would (Kerr) and application of the VivaPen (Ivoclar) bonding
agent, a 1-2 mm layer of ACTIVA BioACTIVE-RESTORATIVE
satisfy the patient’s caregiver while also resisting
was placed.
fracture and wear.

Figure 14. The remainder of the preparation was bulk

Figure 11. Shows failing occlusal lingual composite on filled with ACTIVA BioACTIVE-RESTORATIVE. After light
tooth #A. curing, the restoration was finished and polished.

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Case 3: Closing the Diastema
I see a fair amount of orthodontic relapse
among teenage patients who do not wear
their retainers regularly. Such was the case of
a 16-year-old patient who complained that he
didn’t like the space between his front teeth
(Figure 15).
Figure 15. Shows diastema between teeth #8 and #9
resulting from inconsistent retainer use.
After selecting the appropriate shade, I used
the Bioclear Matrix System, the VivaPen (Ivoclar)
bonding agent and free handing with ACTIVA
to close the diastema (Figure 16). ACTIVA has
somewhat of a chameleon effect, making it
suitable for esthetic restorations. The material
also contains a rubberized resin matrix that
Figure 16. Diastema was closed using the Bioclear Matrix
exhibits high resistance to fracture as shown System and ACTIVA BioACTIVE-RESTORATIVE.
by several university studies. Figure 17 shows a
close-up of the final restoration.

Figure 17. Shows close-up of final restoration. Note the

chameleon effect of ACTIVA BioACTIVE-RESTORATIVE.

Case 4: Treating Hypocalcification and Decay with SDF and ACTIVA

An eight-year-old twin with congenitally
missing teeth presented at my office with
a hypocalcified upper right first permanent
molar (tooth #3) which also had deep decay as
shown in the pre-operative radiograph (Figure
18). The patient’s hypocalcified and decayed
Figure 18: Pre-operative radiograph (contrast
primary molars had been restored four years inverted) from May 2014 shows deep decay near the
earlier under general anesthesia due to high pulp in tooth #3 (upper right 1st permanent molar).
The tooth was asymptomatic.
anxiety. The molar appeared hopeless, and

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another dentist recommended extraction, but
her parents were concerned about her losing
another tooth. Since this was a permanent
tooth, the parents wanted an esthetic
restoration rather than a stainless steel crown.

My materials of choice were MTA, ACTIVA

Base/Liner, and ACTIVA Restorative for the
final restoration due to its wear resistance,
Figure 19: When the patient returned 2 months later, the
toughness, and release of minerals conducive to glass ionomer cement was no longer intact; however, the
tooth was still completely asymptomatic.
sealing and preventing marginal leakage.

With gentle behavior guidance and nitrous

oxide, the treatment was completed with zero
behavior issues. I was concerned about pulpal
exposure or pulpal response to the trauma of
the deep cavity preparation and materials, so
I took a cautious two-step approach. During
Figure 20: Re-opened cavity with infected dentin, which
the initial excavation appointment, I left more was stained black due to the silver ions from silver
infected dentin behind than I normally would, diamine fluoride.

placed a one-minute application of silver

diamine fluoride, and temporized with a glass
ionomer cement.

When the patient returned 2 months later,

the glass ionomer cement was no longer
intact; however, the tooth was still completely
asymptomatic (Figure 19). I reopened the cavity, Figure 21: Carious dentin was removed and the area was
cleaned with a sodium hypochlorite scrub, taking care
which was stained black due to the silver ions to thoroughly excavate all decay at the DEJ but to avoid
pulpal exposure.
from silver diamine fluoride (Figure 20), and
removed more infected dentin until I reached
semi-solid dentin. The area was cleaned with
a sodium hypochlorite scrub, taking care to
thoroughly excavate all decay at the DEJ but to
avoid pulpal exposure. The root apices were not
fully closed at this time (Figure 21). I then placed
NuSmile NeoMTA , which is impenetrable and Figure 22: Shows placement of NeoMTA (NuSmile)

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resists leakage (Figure 22), followed by a 1-2mm
cured layer of ACTIVA BioACTIVE-BASE/LINER to
protect against MTA washout during the acid
etching and bonding procedure.

The tooth was selectively etched and VivaPen

Figure 23: Final Restoration
bonding agent (Ivoclar) was applied. A
2mm initial base layer of ACTIVA BioACTIVE-
RESTORATIVE was placed and light cured for 5
seconds with the VALO light (Ultradent) before
bulk filling the remaining preparation with
ACTIVA BioACTIVE-RESTORATIVE. I felt confident
that I had created the best possible seal against
microleakage for a direct restoration. Figure 23 Figure 24: Three-year follow-up radiograph from June
2017 shows arrested lesion and the deposition of
shows the final restoration. reparative dentin. The tooth was asymptomatic with
complete root formation at the time this radiograph
was taken.
I have followed this case for more than three
years. The pulp remains healthy, there is no
sensitivity, and no marginal breakdown of the
ACTIVA restorative materials. Not only is the tooth
asymptomatic, but there is also radiographic
evidence of a layer of reparative dentin between
the restorative materials and the pulp chamber
(Figure 24). Orthodontic treatment is now
underway for the mal-eruption of the upper right
first bicuspid and multiple missing teeth.

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