Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2011; 56:(1 Suppl): 2330

doi: 10.1111/j.1834-7819.2010.01293.x

Glass-ionomer cement restorative materials: a sticky subject?

SK Sidhu*
*Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Institute of Dentistry, London, United Kingdom.

ABSTRACT
Glass-ionomer cement (GIC) materials have been in clinical use since their inception 40 years ago. They have undergone
several permutations to yield different categories of these materials. Although all GICs share the same generic properties,
subtle differences between commercial products may occur. They have a wide range of uses such as lining, bonding, sealing,
luting or restoring a tooth. In general, GICs are useful for reasons of adhesion to tooth structure, fluoride release and being
tooth-coloured although their sensitivity to moisture, inherent opacity, long-term wear and strength are not as adequate as
desired. They are useful in situations where they are not disadvantaged by their comparatively lower physical properties,
such as where there is adequate remaining tooth structure to support the material and where they are not subject to heavy
occlusal loading. The last decade has seen the use of these materials being extended. However, they are likely to retain their
specific niches of clinical application.
Keywords: Glass-ionomers, resin-modified glass-ionomers, high viscosity glass ionomers, clinical uses.
Abbreviations and acronyms: ART = Atraumatic Restorative Treatment; HEMA = hydroxylmethacrylate; MMGIC = metal-modified
glass-ionomer cement; RMGIC = resin-modified glass-ionomer cement.

glasses have been used. The additives may differ in

INTRODUCTION
Glass-ionomer cement (GIC) materials were invented
four decades ago by Wilson and Kent in 1969 at the
Laboratory of the Government Chemist in London,
United Kingdom.1 These materials form part of the
contemporary armamentarium for restorative dentistry
largely due to their adhesive, tooth-coloured and
fluoride-leaching properties. They are used today in a
variety of clinical situations as restorative, lining, luting
and sealing materials; no other restorative material has
such wide applications. After 40 years of practical use,
they are reasonably well understood and researched.
This paper collates some of the information relevant to
our understanding and clinical use of these materials
and will focus on the restorative applications. Some
evidence is theoretical or scientific, while the rest may
be anecdotal, amassed over a long period of use and
observation.
Basic composition and variants
In simple terms, glass-ionomers are derived from
organic acids and a glass component, and are referred
to as acid-base reaction cements. The acid is generally
an aqueous polymeric acid and the glass is usually a
fluoroaluminosilicate, although other non-fluoride
2011 Australian Dental Association
products available. They are complex materials and no
two commercial systems are chemically or mechani-
cally identical. The setting reaction involves a conven-
tional acid-base reaction initiated on mixing the
components. The maturation of the resultant cement
is relatively slow, with the first 24 hours being
important to maintain the water balance within the
system. The standard protocol for the earlier GICs was
to delay the finishing and polishing stages by at least
24 hours. The emergence of newer improved, rapidly
maturing materials for posterior use has necessitated a
revision of the earlier techniques. However, chemical
maturation may not be achieved in some cements for
24 hours or more, and hence they should be allowed to
mature completely under a protective coating
to optimize their beneficial properties.2 It is difficult
to apply a blanket rule applicable to all GICs,
especially in the absence of well-controlled data,
therefore it may be advisable to delay the polishing
process if at all possible. Finishing and polishing is
often advised with rotary instruments such as flexible
discs, preferably lubricated with a medium such as
petroleum jelly or bonding resin. It is presumed that
this will prevent the restoration from dehydrating and
maintain the all-important water balance in the system
as they are water-based materials.
23
SK Sidhu
Developments in the glass-ionomer category have led
to the introduction of newer materials, resulting in
considerable confusion as to what constitutes a true
glass-ionomer cement material. A material that con-
tains the components of a GIC alone is not necessarily
one. A true GIC is a two-part system characterized by
an acid-base reaction critical to its cure, and continuing
fluoride release.
In an attempt to improve the physical characteristics
of the original materials, additions of metal powders
were introduced. The first such suggestion was a silver
alloy and GIC admixture, with the subsequent emer-
gence of materials incorporating fine metal particles
sintered onto the cement-forming glass to form
ceramic-metal materials or cermets. These cements
with alloy additives, whether or not fused to the glass,
collectively are better referred to as metal-modified
glass-ionomer cements (MMGICs). They are often
described as packable or high viscosity or high requirements of a GIC of having a typical acid-based
powder:liquid ratio GICs, and commercial examples
include Ketac-Silver (3M ESPE, Seefeld, Germany), Hi
Dense (Shofu Inc, Kyoto, Japan) and Miracle Mix (GC
Corp, Tokyo, Japan). They are also sometimes referred
to loosely as metal-reinforced GICs, but this term has
been viewed as somewhat of a misnomer. Although
these cements are said to be superior in terms of
physical properties compared to the conventional GICs,
the literature does not always support this view. In
general, their strength has been found to be less than
satisfactory compared to other posterior restorative
materials for use in high stress-bearing areas3 and they
may not even be better than the conventional high
viscosity GIC materials.4 They do not appear to
perform well clinically in posterior teeth.5
Another such development was the introduction of
the resin-modified glass-ionomer cement (RMGIC)
materials patented in the late 1980s.6,7 This innovation
was an attempt to help overcome the problems
traditionally associated with the conventional materi-
als, i.e. moisture sensitivity and low physical properties
(particularly their early mechanical strength). They
were perceived to be an improvement over the original
materials while still maintaining the clinical advantages
of the traditional GICs, such as adhesion and fluoride
release, offering some measure of protection against
caries. In essence, the RMGICs are glass-ionomer
cements with the incorporation of a small quantity of
monomers as well as initiators involved in the poly-
merization reaction. The fundamental acid-base curing
reaction is supplemented by a second polymerization
reaction. This latter process may be initiated by light, as
in the light-cured RMGICs, which have the ability to
set without light activation although more slowly.
Other versions of RMGICs such as luting cements are
not dependent on light activation. In their simplest
forms, they are GICs with the addition of a small
24
quantity (4.5 to 6%) of resin components, such as
hydroxyethylmethacrylate (HEMA) or Bis-GMA,
although the actual formulation may vary. Some of
the water component of the conventional GIC is
replaced by a water HEMA mixture. The initial set of
these materials is due to the formation of a polymer-
ization matrix while the acid-base reaction hardens and
strengthens the matrix formed. The first RMGIC to be
developed and marketed was a lining cement (Vitre-
bond, 3M Dental, St Paul, MN, USA) but other
versions were subsequently introduced. Their command
set facility made them popular as liners and bases, and
subsequently as restorative materials.
Rapid acceptance of these materials by the dental
profession saw subsequent similar materials appearing
in the marketplace which were variations of the same
theme. However, these latter materials are not all
considered true GICs as they may not fulfill the
glass-ionomer reaction, unlike the RMGICs which are
considered as GICs. By definition, the RMGICs contain
a basic ion-leachable glass, a water-soluble polymeric
acid, organic monomer s and an initiator system.8 The
material must be capable of auto-setting due to the
acid-base reaction, even if designed to be light-cured.
The arrival of the RMGICs did not make the
conventional GICs obsolete; on the contrary, these
latter materials were themselves undergoing exciting
developments of their own. The need for a suitable
material that could be used in conjunction with hand
instrumentation in remote communities where there is
no access to rotary instrumentation and dental care,
was commissioned by the World Health Organization
and this resulted in the development of the high
viscosity GICs. A new restorative technique emerged,
the Atraumatic Restorative Treatment (ART) tech-
nique,9 whereby decalcified tooth tissue can be removed
using hand instruments only, followed by restoration
with an adhesive auto-setting GIC. These material
properties are essential to allow them to be used in any
environment in any part of the world. The high
viscosity GICs in their powder-liquid hand-mixed
version are ideal for this as other restorative materials
require some use of electrically-driven equipment.
The earliest high viscosity material developed for this
purpose was Fuji IX (GC Corp, Tokyo, Japan). The
success of this formulation prompted other manufac-
turers to develop faster-setting GICs with better phys-
ical properties, not just for rural dentistry but for wider
use. Today, these latter materials earn their pride of
place in contemporary restorative dentistry and not
only include Fuji IX but also Ketac Molar (3M ESPE)
and ChemFil Molar (Dentsply DeTrey GmbH, Kon-
stanz, Germany). The changes in the formulation over
the traditional materials included a reduction in the size
of the glass particles in the matrix offering improved
2011 Australian Dental Association

physical properties and stiffer syringeable materials
which allow some degree of packability. Application of
ultrasonic excitation, which appears to increase the
strength of conventional high viscosity GICs, can be
used to set on command and may improve their
survival rate clinically.10
In summary, the broad categories of GICs available
today are the conventional, the resin-modified and the
metal-modified GICs. The latter two categories were
developed in an attempt to overcome the problems of
moisture sensitivity and low mechanical properties
associated with the conventional materials but at the
same time to retain some of their clinical advantages.
Improvements within the conventional GICs have
produced a subgroup of high viscosity GICs.
GICs are presented as hand-mixed powder:liquid
materials or capsulated versions, and more recently
paste systems. Hand-mixed materials require dispens-
ing of the powder which should be mixed with the
liquid in the correct powder:liquid ratio as specified by
the individual manufacturer. Optimal physical proper-
ties are obtained when the powder:liquid ratio as
recommended by the individual manufacturer are
followed. In general, for the conventional GICs,
increasing the powder:liquid ratio improves the
strength but may be difficult to mix by hand. Con-
versely, lowering the ratio from that recommended by
the manufacturer would impair the cements proper-
ties.11
Increasing the powder:liquid ratio results in an
increase in viscosity and a drier mix which may
reduce the ability of the material to effectively wet the
substrate. This may have an effect on the bonding and
ultimately the retention of the restoration.12 The use of
capsulated materials reduces the possibility of errors in
the powder:liquid ratio while mixing, as they are
supplied in capsules containing premeasured amounts
of powder and liquid separated by the liquid which is
encased in a pillow. On activation of the capsule, this
pillow is ruptured and the liquid is expelled through a
narrow orifice onto the powder. The activated capsule
is then mixed mechanically according to the manufac-
turers instructions. It is usually advised that the first
few millimetres extruded from each capsule are dis-
carded before usage. The angled nozzle of the capsules
act as a syringe to facilitate direct placement into a
cavity.
The latest development in the dispensing arena of
GICs is a paste-paste RMGIC, Ketac Nano (3M ESPE)
introduced in 2007. This system uses a specially
designed cartridge and material dispenser or double-
barrelled clicker that delivers defined portions of two
pastes to be mixed by spatulation. This nano-ionomer
material contains an ultra-fine glass powder designed
for this purpose. The exact properties of this material
will undoubtedly be known in the fullness of time.
2011 Australian Dental Association
Glass-ionomer cement restorative materials
General properties
The features of clinical relevance of a restorative material,
especially a GIC, include adhesive properties, marginal
adaptation, biocompatibility, moisture sensitivity, fluo-
ride release, strength, and wear. In general, the GICs are
often thought to suffer from drawbacks such as poorer
physical and aesthetic properties when compared to other
restorative materials. In addition, they are frequently said
to be technique-sensitive due to their moisture sensitivity;
however, this is not unique to the GICs when adhesives
and resin composites are considered.
The RMGICs have some advantages over the con-
ventional materials: greater working time; command
set on application of the relevant light source; earlier
finishing; aesthetics closer to resin-based materials;
better strength characteristics.13 However, they have
not been proven to be superior to the conventional
materials with regard to adhesion, resistance to water
uptake, fluoride release, solubility and biocompatibil-
ity.14,15 They appear to perform well in clinical trials
based on retention, secondary caries and absence of
postoperative sensitivity, but this is not necessarily true
of their marginal characteristics, surface properties and
colour stability.16 In addition, access for placement of
the light-curing tip in some parts of the mouth may
preclude use of these materials.
Adhesive properties
The adhesion of GICs appears to be via mechanical
interlocking of cement in dentinal tubules and the
development of an ion-exchange layer adjacent to the
dentine.17 In practical terms, what does all this mean?
This should translate into good retention within cavities
and the added benefits of prevention of secondary
caries. Is there enough evidence to support this idea?
The evidence for adhesion and retentive properties is
typically conducted on non-carious cervical lesions,
both in the laboratory and clinically, which may appear
fundamentally logical but clinically irrelevant. The
performance in this type of cavity may not necessarily
be extrapolated to other clinical situations and carious
surfaces. Nevertheless, the evidence in this type of
clinical scenario seems to point towards effective
bonding of GICs to tooth structure.18 Conditioning
the dentine surface of the cavity prior to placement of
the GIC is essential for encouraging adhesion of the
cement to the substrate. The bond strength of most
GICs to dentine has been shown to be significantly
higher if the dentine is pretreated.19
Regarding the bond strength of GICs to other restor-
ative materials, overlaying with resin composite may be
desirable and even necessary in some cases such as in
posterior restorations. The shear bond strength of GICs
to composites is said to be sufficient20 and that of the
25
SK Sidhu
RMGICs to resin composite may be significantly higher
than the conventional GICs.21 This may be attributed to
the formation of a catalyst-rich air-inhibited surface
layer on the RMGIC, facilitating bonding by polymer-
izing to the resin composite above.13
Marginal adaptation and microleakage
Marginal leakage can occur due to dimensional changes
and lack of adaptation of the restoration to the cavity
walls. Although the slower-setting conventional mate-
rials are thought to permit stress relief within the
restoration, the RMGICs may exhibit more rapid
setting contraction through the polymerization of the
polymer component. When the RMGIC is extended to
enamel margins, there may be considerable risk of
enamel fracture.22 However, this is not necessarily
borne out by research as the RMGICs appear to display
substantially better adaptation to dentine than the
conventional materials.23 It is possible that a propensity
for water absorption by the HEMA content compen-
sates for the initial setting contraction in the RMGICs.
Biocompatibility: biological and pulpal effects
In a review of the literature on biocompatibility of
GICs, the authors concluded that most aspects of the
GICs allow a reasonable margin of tolerance from a
biocompatible standpoint.15 However, they emphasize
that the biologic properties are product-specific. While
the initial pulp reactions to some products appear to
resolve in time, especially if there is a dentine barrier,
the long-term effects of direct application of GIC to
pulp tissue are largely unknown.
Glass-ionomers have been much maligned in the past
due to the fear of elution of ions such as aluminium
which may have the potential for profound biological
effects. Whether this actually occurs is highly debat-
able, as there would be far more reports of adverse
reactions if this were the case. A recent paper reviewed
the role of aluminium in GICs and concluded that this
ion is leached in varying degrees; however, it is largely
excreted and poses a negligible health hazard.24
Concern has been previously raised regarding the
biocompatibility of the RMGICs in particular as they
contain unsaturated groups.15 They cannot be consid-
ered biocompatible to the same extent as conventional
GICs.25 Moreover, the RMGICs are considered to
produce a polymerization exotherm and greater tem-
perature rises than conventional GICs;26 however, this
has not been shown to be a clinical issue.
Moisture sensitivity
The complex nature of the setting reaction of GICs is
often blamed for the moisture sensitivity, especially in
26
the early stages and beyond. The need to maintain the
water balance in GICs, particularly in the early phases
of their maturity, has led to the recommendation that
the surface of a newly placed glass-ionomer be pro-
tected from water loss and, equally importantly, from
water gain. Various materials have been used including
copal varnish, light-cured bonding resins, petroleum
jelly and cocoa butter. Early protection with light-cured
resins or commercial varnishes reduces their vulnera-
bility to dissolution and deterioration of physical
properties.
The effect of a waterproof coating on the fluoride
release by a GIC system has been debated;2 however, it
is doubtful if the resins used as coating agents remain
on the surface long enough to prevent this, while their
presence in the short-term is beneficial in protection.
Another advantage of using a coating agent is the
potential to fill surface voids and defects, reducing the
uptake of stains from food and drinks.
The RMGICs are thought to be less prone to
moisture sensitivity due to the resin network reducing
the diffusion of water into the cement and hence
protecting the cement from dissolution by early contact
with water. However, this may not be the case as they
appear to be susceptible to dehydration27 as well as
having the potential to take up water from the
environment;28 this may ultimately affect their proper-
ties such as strength and colour stability and could
affect the bonding interface.29 One of the greatest
advantages of the RMGICs over their conventional
counterparts is earlier finishing and polishing; however,
it has been suggested that the water balance in these
materials is just as critical30 which may have implica-
tions for finishing soon after initial set.
Fluoride release: the role of fluoride and
anticariogenicity
The fluoride-releasing properties of GICs is probably
one of their greatest assets. It is assumed that the GICs
have a caries-inhibitory effect which is due to their
long-term and sustained fluoride release. Fluoride is
used as a flux during the manufacturing process of the
glass powder and is not a matrix-forming species; this
fluoride is available for release from the set cement to
influence the immediate surrounding tooth tissue as
well as any adjacent surface. However, the inherent
fluoride is depleted fairly quickly within the first few
months. Nevertheless, the cement has the capacity to
take up more fluoride from the ambient environment,
depending on the concentration gradient. It is thought
that this may continue for the life of the restoration and
hence the GIC acts as a fluoride reservoir. This
rechargeability31 is particularly advantageous where
there is a high caries rate. Hence, they are known as
bioactive or smart materials as they are not passive,
2011 Australian Dental Association
 Glass-ionomer cement restorative materials

but instead react to the environment. The fluoride

release of the RMGICs is just as good, although the
amount and rate of release by different restorative
products may vary.32
The critical level of fluoride released by a material
for effective caries inhibition has not yet been
established, often working on the premise that the
more fluoride released over a longer period, the better.
The GICs are thought to be rechargeable fluoride
systems with their ability to be recharged by fluoride
exposure in solution, hence acting as reservoirs of
fluoride which may be released into saliva, plaque and
dental tissues,33 over time and given the right condi-
tions.31
It is thought that the fluoride release from GICs is
responsible for the bacterial inhibition associated with
these materials (especially against Streptococcus
mutans), although this has been recently disputed.34
Hence, the fluoride release may not be the only
mechanism of antibacterial action as other components
(such as aluminium and strontium) have also been
implicated.35,36 Perhaps this antibacterial property
could account for the lower incidence (anecdotal) of
gingival inflammation immediately adjacent to cervical
GIC restorations. The MMGICS appear to have a lower
antibacterial effect compared to the RMGICs.37
In spite of laboratory and anecdotal evidence that Fig 1. RMGIC used to restore the cervical lesion in tooth 21.
GICs show cariostatic properties, this is often not borne (Courtesy of Professor Martin Tyas, Australia.)
out in clinical studies on the incidence of secondary
caries.38,39 Clinical data are conflicting as to whether
GICs have an effect on secondary caries. This may be
due to the methods for clinical evaluation of GICs
which need to be appraised38 and does not explain the
anecdotal evidence to support the effect of GICs on the
immediate surroundings as well as adjacent surfaces. Is
this a serendipitous outcome?

Clinical uses of GICs

The common attributes of adhesion and fluoride release
make these materials useful for a variety of clinical
situations. While other restorative materials have
enjoyed a largely constant number of indications for
their use, the list of indications for GICs has steadily
grown.
Notwithstanding, a common indication for GICs as
restorative materials is the non-carious cervical lesion,
where the need for cavity preparation and mechanical
retention is reduced (Figs 1a and 1b). These materials
have particularly good potential in root caries, not
uncommon in an ageing population, due to their
adhesive qualities and fluoride release (Figs 2a and
2b). Such lesions do not lend themselves to ideal cavity
preparations, particularly those that present as encir-
cling defects around the cervical margin. Fig 2. Carious cervical lesions before and after restoration with
RMGIC. (Courtesy of Dr Sueo Saito, Japan.)
2011 Australian Dental Association 27
SK Sidhu
Glass-ionomers have been traditionally used in non
or minimal load-bearing situations. Their use in pos-
terior teeth has been limited by their physical proper-
ties. However, the need for a tooth-coloured material
with relatively easy handling properties prompted the
development of the high viscosity GICs. The main
reasons for this was the need to find a replacement for
the traditional amalgam as well as the need for the use
of a material in what is now the well-established ART
technique (see above) in areas where there is no access
to rotary instrumentation and dental care, such as in
rural communities and many developing countries, and
is predicated on the use of a high viscosity GIC. Short-
term results show that this approach has increased the
ratio of restorations to extractions in these popula-
tions.40 The question remains regarding the extent to
which this technique can be extended to the wider
population and is an effective public health measure.
The high viscosity GICs may be selected for occlusal
and approximal carious lesions in primary and perma-
nent posterior teeth, provided that they can be conser-
vatively prepared and restored within the limits of the
relevant occlusion and not be subjected to heavy
occlusal load. Glass-ionomers have not performed well
in clinical studies on longevity of posterior restorations
under load.41,42 Thus, in high load areas overlaying
them with a more durable material such as resin
composite would make clinical sense. In the cervical
lining (open sandwich) technique, it is recommended
that the glass-ionomer should be kept well below the
contact area otherwise it may dissolve (Figs 3a and 3b);
progressive loss of material in approximal areas, just
below contact areas, was commonly observed in a six-
year study using a high viscosity GIC in approximal
cavities, leading the authors to conclude that the
presence of approximal contacts promotes disintegra-
tion of the GIC.43
What the GICs may be suited for are microcavity
designs for conservative treatment of approximal
(a) (b)
Fig 3. (a) Radiograph showing approximal dissolution of GIC where
it had been extended to immediately below the contact area. (b) Ideal
outline of the extent of the glass-ionomer when restoring an
approximal lesion. (Courtesy of Professor Martin Tyas, Australia.)
28
lesions, which are essentially an occlusal approach to
an approximal lesion. At present, the GICs are not
designed to be placed under direct occlusal load so they
should be overlaid with another more durable material
such as a resin composite. The effectiveness of the
tunnel approach to the traditional approximal prep-
aration was reviewed and it was concluded that tunnel
restorations restored with GICs are technically deficient
and have a limited life-span;39 they were not recom-
mended as alternative preparations for approximal
lesions. Glass-ionomers can be considered only as
long-term provisional restorations in stress-bearing
posterior cavities.44
Caution must be exercised in the use of any GIC in
core build-ups if there is little coronal tooth structure
present to support a core build-up,45,46 as their physical
properties do not lend themselves to this; they may be
used as space-fillers until further improvements are
made. Although the MMGICs appeared to be promis-
ing as core build-up materials,47 their physical proper-
ties and lack of adhesion to tooth structure make them
less than ideal for this purpose.48 Also, it is advised
against routinely preparing a tooth whose core includes
a GIC (even if it is an RMGIC) at the same visit as
placement, as the level of maturity would not have been
fully established.
In an era of minimum intervention dentistry, rather
than replacement dentistry, perhaps more consideration
could be given to repairs of open margins, marginal
defects around castings, etc. in the absence of a
compelling need to otherwise replace or remake a
restoration. This should not, however, be a compromise
accepted in the presence of inadequate dentistry. Glass-
ionomers may be very useful in this indication. They
can also be used to repair perforations (Figs 4a and 4b).
(a) (b)
Fig 4. (a) Resorptive defect in tooth 11. (b) Defect repaired with GIC.
(Courtesy of Dr Justin Barnes, United Kingdom.)
2011 Australian Dental Association

In summary, the GICs may be useful as liners and
bases, for anterior approximal restorations, cervical
restorations (both carious and non-carious), core build-
ups where there is sufficient remaining tooth structure,
occlusal and small approximal restorations in decidu-
ous teeth, microcavities, internal and tunnel prepara-
tions, temporary repairs of fractured teeth, temporary
repairs of defective crown margins, retrograde root
fillings and root perforation repairs.
CONCLUSIONS
GICs are mainstream restorative materials that are
bioactive and have a wide range of uses such as lining,
bonding, sealing, luting or restoring a tooth. It is
important to recognize that although the GICs share the
same generic properties, subtle differences between
commercial products may occur. The RMGICs appear
to have properties intermediate to the conventional
GICs and resin composites and are often considered a
hybrid of the two materials.
In general, GICs are useful for reasons of adhesion to
tooth structure, fluoride leaching and being tooth-
coloured, although their sensitivity to moisture, inher-
ent opacity, long-term wear and strength are not as
adequate as desired. They are useful in situations where
they are not disadvantaged by their comparatively low
physical properties, such as where there is adequate
remaining tooth structure to support the material and
where they are not subject to heavy occlusal loading.
The last decade has seen the use of these materials being
extended. However, they are likely to retain their
specific niches of clinical application.
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Address for correspondence:
Dr Sharanbir K Sidhu
Clinical Senior Lecturer Honorary Consultant
Centre for Adult Oral Health
Queen Mary University of London, Barts and
The London School of Medicine and Dentistry
Institute of Dentistry
Turner Street, London E1 2AD
United Kingdom
Email: s.k.sidhu@qmul.ac.uk
2011 Australian Dental Association