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Advances in Tooth-Colored Restoratives

A Peer-Reviewed Publication Written by Lou Graham, DDS

Publication date: December 2010 Expiry date: November 2013

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Supplement to PennWell publications. This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Educational Objectives
The overall goal of this article is to provide dental professionals with information on tooth-colored restorations. Upon completion of this course, the clinician will be able to do the following: 1. Describe the early tooth-colored direct restorative materials 2. List and compare the attributes of composite resins and glass ionomer cements 3. Describe the composition of a compomer, and compare it to composite resins and conventional glass ionomers 4. Describe the restoratives containing nanotechnology and the effect of nanotechnology in nano-ionomer restorations

Abstract
Researchers have developed multiple tooth-colored restoratives in the search for a material that has optimal strength, esthetics, handling properties and a preventive function. Materials currently available include glass ionomer-based materials, composite-based materials, compomers, giomers, and the use of nanotechnology for composites and nanoionomers. Each offers benefits for the individual patient case.

Introduction
The quest for suitable tooth-colored restoratives began with the introduction of acrylics and silicates. While weak and offering relatively poor esthetics, as well as being difficult to accurately mix and handle, they represented the first efforts at providing the clinician and patient with both esthetics and functionality in a restoration. As researchers investigated various chemistries, two main categories of direct tooth-colored restorations evolved composite resins and glass ionomer cements. These represented a significant improvement over the pre-existing options, which rapidly fell out of favor. Figure 1. Development of early tooth-colored restoratives

leakage and sensitivity, and subject to considerable surface wear as a result of their relatively low surface hardness.1 Wear resistance and strength were subsequently improved such that posterior composites were introduced, although initially these, too, were unsatisfactory for heavy stress-bearing situations.2 The current range of composite resin restoratives offers the greatest strength and wear resistance of all direct tooth-colored materials and continues to be the most esthetic option. Current adhesive techniques have resulted in improved bonding of the tooth-adhesive and adhesive-composite interfaces, although marginal leakage is still a consideration. Composites typically do not contain fluoride, and the fluoride release from fluoride-containing composites has been found to be minimal; at the same time, biofilm adheres well and grows on rough composite surfaces.3 Composites are now differentiated based on filler type and load as well as unique chemistries such as those utilized to reduce polymerization shrinkage and stress. The physical characteristics of composites have become well-differentiated microfilled composites offer the ability to polish and retain a high gloss and superior esthetics, while microhybrid composites offer greater strength but result in uneven wear due to the loss of large filler particles.4 Most recently, nanotechnology has been introduced into composites and is discussed later in this article.

Glass Ionomer Cements

Glass ionomer cements consist of two components that initially were available only as a powder and liquid. Fundamentally, these consist of fluoroaluminosilicate glass particles and an aqueous solution of polyalkenoic (or polyacrylic) acid. A major difference between glass ionomer restoratives and composite-based restoratives is the inclusion of water in the glass ionomer formulations and their hydrophilicity, which results in wet contact with the tooth surface and a strong bond over time. The setting reaction for glass ionomers is acidbased, rather than setting through polymerization; therefore, no polymerization shrinkage can exist. Using infrared spectroscopy and band-narrowing treatments to assess materials, Arrondo et al. confirmed that glass ionomers set through an acid-based reaction as well as cross-linking of the polycarboxylate with the metal ions present in the glass ionomer.5 Glass ionomer cements tolerate moist environments and are applied to moist tooth surfaces. In addition, they adhere directly to the tooth structure and provide a solid marginal seal. In combination, these attributes can provide for an easier and quicker chairside experience for patient and clinician alike compared to using composite resins. In general, however, glass ionomer cements have lower strength than composites. One of the main benefits of glass ionomers is their ability to release fluoride. Based on studies of up to three years duration, fluoride release is ongoing; the amount released exceeds the initial fluoride content of the fluoroaluminosilicate glass particles demonstrating the uptake of fluoride from external sources and has been found to be regulated by the phosphowww.ineedce.com

1940s Acrylics and silicates

1950s Composite resins

1970s Glass ionomer cements

Composite Resins
Composite resins fundamentally consist of two phases: the filler content and the monomer-based content, typically bisphenol A glycidyl dimethacrylate (bis-GMA), tetraethyleneglycol dimethacrylate (TEGDMA) or dimethacrylate (DMA). Setting occurs strictly through polymerization of the monomers, resulting in the fillers being dispersed in the set polymer. Early composite resins were relatively weak, with low compressive strength, tensile strength and flexural strength, and they exhibited a high degree of polymerization shrinkage and shrinkage stress. They were also poorly bonded to the clinical site with primitive adhesive techniques, resulting in marginal
2

rus at the glass ionomer surface.6 The fluoride release from glass ionomers has been shown to help prevent the formation of secondary caries, by creating a zone of inhibition, and in addition has been found to have a preventive effect on adjacent teeth.7 Since the main reason for replacement of direct restorations is secondary caries, caries inhibition through fluoride release is highly desirable.

Bridging the Gap

As a result of their respective attributes, resin-based composites became the material of choice where strength and esthetics were of greatest importance. Glass ionomers have been favored in situations where caries control, the intraoral environment and ease of placement were more important considerations than strength and esthetics. Improving the strength and esthetic properties of both composites and glass ionomers became a strong focus, as well as improving specific attributes (such as reducing polymerization shrinkage in resin-based composites). Researchers investigated and continue to investigate potential solutions that might offer all the benefits of composites and glass ionomers but without any of the drawbacks associated with either category. In the quest for a single material that might meet all requirements for the ideal restorative, composites and glass ionomers have both evolved. Chemistry from each category has been incorporated into the alternative restorative material, with differentiation of fillers, unique chemistries, delivery systems, curing mechanisms, and single-layer versus multi-layer techniques.

around the hydroxyapatite as well as to the hybrid layer (depending on the product), which resulted in micro-mechanical bonding through an interlocking mechanism.10 Interestingly, and as a note of caution, no hybrid layer or gel phase is found using the same protocol on Er:YAG laser-irradiated dentin, nor any dentin demineralization or collagen melting.11 A separate study comparing the adhesion mechanism of bur-cut and laser-irradiated dentin supports these results; although partial demineralization was observed, there was still no hybrid layer formation. It was also determined that the use of glass ionomer conditioner was important for microtensile bond strength in bur-cut dentin.12 The fracture resistance of resin-modified glass ionomers has been found to be significantly greater than that of conventional glass ionomers. In addition, a reduction in particle size (of up to 10 microns) of the fluoroaluminosilicate-based component has been found to increase fracture resistance as well as result in a smooth surface.13 Resin-modified glass ionomers are still not a material of choice for posterior stress-bearing areas, due to their relatively low surface hardness and fatigue resistance.14,15 Light-activated glass ionomers enable immediate finishing and reduced incidence of subsequent microleakage.16 Metal-reinforced Glass Ionomers Metal-reinforced glass ionomers include metal ions in the mix typically silver-based alloys such as the silver-tin alloy found in amalgam. These are used primarily for core buildups and are also used to restore primary molars. A subset of this category, the cermet, results from fusing the metal ions to the fluoroaluminosilicate glass particles; however, cermets release less fluoride than other glass ionomers.

Resin-modified Glass Ionomers

The strength of glass ionomers was improved through the addition of methacrylate monomer in the aqueous polyalkenoic acid solution as well as the addition of monomer containing free radical double bonds in the fluoroaluminosilicate-containing component. This created a new subset within the category that was named resin-modified glass ionomer cement. The monomer sets through polymerization when light-activated and cross-links, but does not interfere with the acid-based setting reaction due to the limited amount added to the glass ionomer.8,9 Light-curing of these glass ionomers offers control whereby the initial self-setting is accelerated. After exposure to polyalkenoic acid conditioner, resin-modified glass ionomer forms a hybrid layer at the dentin surface of bur-cut dentin and a typical submicron gel phase can be observed with transmission electron microscopy. Assessments in laboratory testing found that the direct bonding to the tooth structure was attributable to bonding of the gel phase Figure 2. Material categories
Glass ionomers Resinmodi ed glass ionomers Metalreinforced glass ionomers and cermets

Compomers
Compomers, also known as polyacid-modified resin composites, were developed from composites. They contain filler similar to the glass particles contained in glass ionomers, dimethacrylate monomer and polyacid, but they do not contain water. Setting occurs through polymerization and, as with conventional composites, adhesion is achieved through the mandatory use of bonding agents rather than direct bonding to the tooth structure.17 Based on the absence of a COO bond, it was determined that no acid-based reaction occurs. Finally, it was also concluded that the release of metal ions that chelate with the methacrylate-based polymer molecules was due to dilution of filler particles through the presence of water.5 Compomers have lower compressive strength and flexural strength, a lower Youngs modulus (modulus of elasticity), and reduced resis-

Nanotechnology Nanoionomers Nano lled composites Micro lled and microhybrid composite resins Early composite resins

Giomers

Compomers

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tance to fracture and wear compared to composites, and should not be used in stress-bearing areas.18,19,20 A study comparing tooth-colored restorative materials found that the surface finish of glass ionomers and compomers were both significantly poorer than that of conventional composites.21 Biofilm development is significant on both compomer and composite materials. The glass particles in compomers are responsible for the fluoride release from the set compomer which, while lower than with glass ionomers, is still ongoing.22,23,24,25,26 There have been concerns about the release of HEMA from compomers,26 due to the risks of adverse pulpal responses in patients and of allergy in patients and dental personnel. The amount of HEMA released is influenced by the individual material, depth of cure and degree of curing.27,28 Although compomers do not meet esthetic requirements where these demands are primary, some offer greater polishability than glass ionomers and resinmodified glass ionomers.18 Compomers may be suitable for restorations where neither strength nor esthetics are primary considerations, such as in pediatric restorations, and have also been used as orthodontic bonding agents.

Nano-ionomers
Nano-ionomers were developed with the desire to combine the proven benefits of glass ionomers, in particular fluoride release, with the proven benefits of nanotechnology available in resin-based composites discussed above notably improved esthetics, surface smoothness, strength and wear resistance. The nano-ionomer consists of one paste containing water, polycarboxylic acid, nanofillers and reactive resins. With the exception of the nanofillers, these components are contained in resin-modified glass ionomers and compomers. The other paste contains a combination of nanofillers (based on silica and zirconia) and nano-clusters of these fillers, together with reactive resins and 27% fluoroaluminosilicate glass particles. The nano-ionomer is placed and light-cured after use of its corresponding primer. It is essential that the primer be used to optimize tensile shear bond strength. In assessing the interface and the material, nano-clusters with a high filler load and good distribution of the filler through the nano-ionomer (KetacTM Nano, 3M ESPE) have been observed, together with bonding through micromechanical locking.32 Korkmaz et al. studied the shear bond strength of nano-ionomer to enamel and dentin after use of primer with or without the addition of 37% phosphoric acid etching, with some specimens receiving laser etching first. It was found that the use of only primer resulted in the greatest shear bond strength in dentin; in enamel, use of phosphoric acid provided the greatest bond strength. Interestingly, as with the resin-modified glass ionomers discussed earlier, laser treating the tooth structure prior to use of the primer and nano-ionomer results in poor shear bond strengths.33 The setting reaction of the nanoionomer involves the rapid free radical polymerization of the monomers when exposed to light-curing, followed for a much longer time by a slower acid-base reaction involving the fluoroaluminosilicate glass filler and aqueous acid solution. The nano-ionomer has been found to have compressive strength at least equal to conventional glass ionomers and resin-modified glass ionomers, to have good flexural strength and diametral tensile strength, and to be less brittle than resin-modified Figure 3. SEM of nano-ionomer

Giomers
Another approach has been the use of milled, silanized glass ionomer fillers that have already undergone the acid-base reaction between fluoroaluminosilicate glass and polyalkenoic acid prior to milling. These fillers are then used in a composite resin base to provide fluoride release from the fillers together with the strength and esthetics of composites and have been found to be successful in these regards.29

Nanotechnology
The introduction of nanotechnology, initially in composites, heralded improved esthetics without compromising strength or wear resistance. Strength and wear resistance were also improved, depending on the material.

Nanofilled Composite Resins

Nanofilled composite resins were designed to combine the polishability and esthetics of microfilled composites with the strength and wear resistance of microhybrid composites. They contain nanofillers that are heavily loaded into the composite; these improve the translucency and opalescence of the composite, making it more natural looking and better able to blend in with the surrounding area.4 The addition of nanosized particles to composite resins increases their polishability. Azevedo et al referred to the recent studies suggesting that these particles should ideally be evenly dispersed together with microfillers.30 Nanofilled composites offer improved strength compared to microfilled composites and equal to or better than other composites.31 The addition of pre-polymerized nanofillers forming nanoclusters has been found to reduce polymerization shrinkage, further increase strength and esthetics, and offer a smoother surface that is less subject to wear and that wears more evenly.4
4

Courtesy of Dr. William Douglas and Dr. Daranee Tantibirojn

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glass ionomers. Equivalent fluoride release and recharge occur, and the inclusion of nanofillers in the material results in a smooth surface, with wear resulting in loss of the fine particles (as with nanofilled composites). The end result of use of the nanotechnology is a nano-ionomer that offers greater strength, the esthetics of nanotechnology and the release of fluoride on an ongoing basis.

Experimental Approaches
Experimental fillers such as trimethyletoxysilane and the use of N-vinylpyrrolidone have been investigated as additives to composites and glass ionomer cements, and the inclusion of a methacryloyl derivative of l-proline in glass ionomers was found to result in greater diametral tensile strength, higher compressive strength and higher biaxial flexural strength.30,34,35 Nanosized particles of nanohydroxyapatite and fluorapatite were created and incorporated into glass ionomer cement in another study, resulting in increased bond strength, compressive strength, diametral tensile strength and flexural strength.36 One investigation involved creating novel fillers for a resin-based composite by combining ground cured glass ionomer with ceramic whiskers composed of silica fused onto silicon nitride that were then silanized. The resulting material was found to have superior flexural strength and moderate fluoride release, the degree of release influenced by the proportions of ground glass ionomer and ceramic whiskers.37 Experimental light-cured HEMA-free glass ionomer cements have been studied and found to offer promise.38 Self-etch adhesives to further strengthen adhesion to tooth structure have also been researched for both composites and resin-modified glass ionomers.39 Handling and Placement As with restorative materials themselves, substantial developments have occurred with the mixing and application of tooth-colored restoratives. Initially, glass ionomers consisted of powder and a water and polyacrylic acid-based liquid, and were always hand-mixed. Similarly, early composites consisted of two pastes and they, too, were hand-mixed. There was no possibility of a one-component delivery system, nor did mixing tips/double-barrel applicators exist. Currently, a number of options are available for the handling and application of composites and glass ionomers as well as their derivative products. For composites, one option is a multi-dose syringe from which the material is extruded onto a mixing pad before being applied to the tooth; another is direct application from a unit-dose capsule or, for flowable composites, directly into the preparation from a disposable single-use applicator tip on a multi-dose syringe. Focus has also been placed on the shapes of the syringes, the amount of pressure required for extrusion of the material, the hand grip and thumb comfort during extrusion, methods for measuring the amount extruded (such as clicks or lines representing an average extruded dose), and the overall ease of use. Although
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still available, hand-mixed dual-paste composites are difficult to mix accurately and without the inclusion of voids. For glass ionomers and resin-modified glass ionomers, several options exist. These include the use of a powder and liquid, or pastepaste (using the same hand-mixing method used for early glass ionomers) and the use of a unit dose that is activated by pressing on, or twisting, the unit dose and then triturated for 10 to 15 seconds (product dependent) before being applied directly to the preparation with or without the use of an applicator. A third option is the use of a Paste Pak that is placed in an applicator, after which a disposable mixing tip is added to mix premeasured amounts of each component and to dispense the material onto a pad or directly to the site of use. Figure 4. Unit doses, powder liquid, syringes

The use of predosed, as well as premixed, materials automatically regulates the quality of the mix as well as the appropriate proportion of components. This is important, since measuring and mixing errors can result in incorrect ratios of two-component materials that will lead to reduced strength and surface hardness of the final restoration. One study found resin-modified glass ionomers less affected than traditional glass ionomers and other materials, but not immune to these effects.40 Nonetheless, depending on whether a disproportionate amount of powder or liquid is used in a hand-mixing system without premeasuring, it has been found that surface hardness, flexural strength and fracture resistance can be affected.41,42 This led to the researchers in one investigation advocating the use of precapsulated unit doses.42 A nanoionomer (Ketac Nano) utilizes a novel unit dose that does not require activation or trituration and can be applied to the preparation after taking it out of its foil pouch and placing it in the matching applier (AplicapTM, 3M ESPE). This approach provides premeasured unit dosing with mixing occurring as the material is extruded through the mixing tip built into the unit dose itself. This system can save time and provides ease of use. Alternatively, if preferred, the same nano-ionomer can be dispensed as two separate premeasured pastes from a dual-paste double-barrel syringe system clicker dispenser and hand-mixed prior to direct application to the preparation using hand instruments.
5

Figures 5a and 5b. Unit dose and Aplicap

Figure 7. Application of primer

Clinical Application
The two cases below illustrate the use of nano-ionomer for anterior restorations.

Figure 8. Air-drying of primer

Case 1.
The patient presented with a large distal and buccal carious cavity on tooth #27 which served as the support for a partial denture clasp. An esthetic, wear-resistant restoration was required, and it was decided to create a closed-sandwich restoration using nano-ionomer and composite. After applying primer (Ketac Nano), a stand-alone air syringe was used (rather than a three-in-one air-water syringe) to maximally air-dry the primer and avoid any possible contamination of the site with water prior to light-curing. Nano-ionomer (Ketac Nano) was then placed in the site for the internal sandwich layer and light-cured, with the lightcuring tip held close to the material to ensure maximum cure. Once cured, a soft composite finishing bur was used to prepare the surface of the nano-ionomer, after which a total-etch technique was used for bonding (XP Bond, Dentsply Caulk) of the composite to the enamel. The composite (FiltekTM Supreme A3, 3M ESPE) was then placed and the composite light-cured and finished. The end result was a durable, esthetic restoration. Figure 6. Disto-buccal cervical lesion

Figure 9. Light-curing of primer

Figures 10a and 10b. Application of nano-ionomer

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Figure 11. Light-curing of nano-ionomer

ished using a finishing bur. To help prevent recurring caries and to recharge the nano-ionomer with fluoride, the patient was then placed on a preventive protocol that involved the use of ClinproTM 5000 with TCP (3M ESPE) in the morning and Crest PRO-HEALTHTM (Procter and Gamble) toothpaste in the evening, followed by MI PasteTM (GC America) in a custom-made soft tray overnight. Figure 14. Carious cervical lesions under fixed prosthesis

Figure 12. Nano-ionomer prepared prior to composite placement

Figure 15. Excavation of caries

Figure 13. Finished closed-sandwich restoration

Figure 16. Application of primer

Figure 17. Application of nano-ionomer

Case 2.
The patient in this case was an 89-year-old woman with xerostomia. She presented with extensive carious cervical lesions under a fixed anterior prosthesis, indicative of high caries activity, and the selected clinical solution was use of nanoionomer. Primer (Ketac Nano) was applied, dried using an air syringe and light-cured. For the restorations, nano-ionomer (Ketac Nano) was applied and shaped using a plastic instrument prior to light-curing. The final restorations were finwww.ineedce.com 7

Figures 18a and b. Final cervical restorations

Summary
Tooth-colored restorations have changed greatly since their initial introduction. Over time, these have developed to include several types of packable composites, flowable composites, glass ionomers and compomers and the use of nanotechnology. When selecting a material, the requirements for the patient and individual restorations are factors of paramount importance.

References
Eliades GC, Caputo AA, Vougionklakis A. Composition, wetting properties and bond strength with dentin of six new dentin adhesives. Dent Mater. 1985;1:170-6. 2 Wilson EG, Mandradjieff M, Brindock T. Controversies in posterior composite resin restorations. Dent Clin North Am. 1990;34(1):2744. 3 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial analysis of amalgam and composite resins. J Dent. 2007;35(3):201-6. 4 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90. 5 Arrondo JLR, Collado MI, Soler I, Triana R, Ellacuria J. Setting reaction of polyacid modified composite resins or compomers. Open Dent J. 2009;3:197-201. 6 Billington RW, Williams JA, Pearson GJ. Ion processes in glass ionomer cements. J Dent. 2006;34(8):544-55. 7 Qvist V, Poulsen A, Teglers PT, Mjr IA. Fluorides leaching from restorative materials and the effect on adjacent teeth. Int Dent J. 2010;60(3):156-60. 8 Mount GJ, Patel C, Makinson OF. Resin modified glass-ionomers: strength, cure depth and translucency. Aust Dent J. 2002;47(4):33943. 9 Berzins DW, Abey S, Costache MC, Wilkie CA, Roberts HW. Resin-modified glass-ionomer setting reaction competition. J Dent Res. 2010;89(1):82-6. 10 Coutinho E, Yoshida Y, Inoue S, Fukuda R, Snauwaert J, Nakayama Y, De Munck J, Lambrechts P, Suzuki K, Van Meerbeek B. Gel phase formation at resin-modified glass-ionomer/tooth interfaces. J Dent Res. 2007;86(7):656-61. 11 Delm KI, Cardoso MV, Mine A, De Moor RJ, Van Meerbeek B. Transmission electron microscopic examination of the interface between a resin-modified glass-ionomer and Er:YAG laserirradiated dentin. Photomed Laser Surg. 2009;27(2):317-23. 8 1

12 Cardoso MV, Delm KI, Mine A, Neves Ade A, Coutinho E, De Moor RJ, Van Meerbeek B. Towards a better understanding of the adhesion mechanism of resin-modified glass-ionomers by bonding to differently prepared dentin. J Dent. 2010;38(11):921-9. Epub 2010 Aug 20. 13 Mitsuhashi A, Hanaoka K, Teranaka T. Fracture toughness of resinmodified glass ionomer restorative materials: effect of powder/liquid ratio and powder particle size reduction on fracture toughness. Dent Mater. 2003;19(8):747-57. 14 Gladys S, Van Meerbeek B, Braem M, Lambrechts P, Vanherle G. Characterization of glass ionomer cements containing resin. Rev Belge Med Dent. 1996;51(1):36-53. 15 Burgess JO, Norling BK, Rawls HR, Ong JL. Directly placed esthetic restorative materials the continuum. Compend Contin Educ Dent. 1996;17(8):731-2. 16 Wilder AD Jr, Swift EJ Jr, May KN Jr, Thompson JY, McDougal RA. Effect of finishing technique on the microleakage and surface texture of resin-modified glass ionomer restorative materials. J Dent. 2000;28(5):367-73. 17 Martin R, Paul SJ, Luthy H, Scharer P. Dentin bond strength of Dyract Cem. Am J Dent. 1997;10:27-31. 18 Gladys S, Van Meerbeek B, Braem M, Lambrechts P, Vanherle G. Comparative physico-mechanical characterization of new hybrid restorative materials with conventional glass-ionomer and resin composite restorative materials. J Dent Res. 1997;76(4):883-94. 19 Meyer JM, Cattani-Lorente MA, Dupuis V. Compomers: between glass-ionomer cements and composites. Biomaterials. 1998;19:52939. 20 Ruse ND. What is a compomer? J Can Dent Assoc. 1999;65:500-4 21 Yap AU, Yap SH, Teo CK, Ng JJ. Comparison of surface finish of new aesthetic restorative materials. Oper Dent. 2004;29(1):100-4. 22 Musa A, Pearson GJ, Gelbier M. In vitro investigation of fluoride ion release from four resin-modified glass polyalkenoate cements. Biomaterials. 1996;17:1019-23. 23 Grobler SR, Rossouw RJ, Van Wyk K. A comparison of fluoride release from various dental materials. J Dent. 1998;26:259-65. 24 Shaw AJ, Carrick T, McCabe JF. Fluoride release from glassionomer and compomer restorative materials: 6-month data. J Dent. 1998;26:355-9. 25 Asmussen E, Peutzfeldt A. Long-term fluoride release from a glass ionomer cement, a compomer, and from experimental resin composites. Acta Odontol Scand. 2002;60(2):93-7. 26 Kawai K, Takaoka T. Fluoride, hydrogen ion and HEMA release from light-cured GIC restoratives. Am J Dent. 2002;15(3):149-52. 27 Palmer G, Anstice HM, Pearson GJ. The effect of curing regime on the release of hydroxyethyl methacrylate (HEMA) from resinmodified glass-ionomer cements. J Dent. 1999;27(4):303-11. 28 Beriat NC, Nalbant D. Water absorption and HEMA release of resin-modified glass-ionomers. Eur J Dent. 2009;3(4):267-72. 29 Ikemura K, Tay FR, Endo T, Pashley DH. A review of chemicalapproach and ultramorphological studies on the development of fluoride-releasing dental adhesives comprising new pre-reacted glass ionomer (PRG) fillers. Dent Mat J. 2008;27(3):315-39. 30 Azevedo C, Tavernier B, Vignes JL, Cenedese P, Dubot P. Structure and surface reactivity of novel nanoporous alumina fillers. J Biomed Mater Res B Appl Biomater. 2009;88(1):174-81. 31 Beun S, Glorieux T, Devaux J, Vreven J, Leloup G. Characterization of nanofilled compared to universal and microfilled composites. Dent Mater. 2007;23(1):51-9. 32 Coutinho E, Cardoso MV, De Munck J, Neves AA, Van Landuyt KL, Poitevin A, Peumans M, Lambrechts P, Van Meerbeek B. Bonding effectiveness and interfacial characterization of a nano-filled resinmodified glass-ionomer. Dent Mater. 2009;25(11):1347-57. 33 Korkmaz Y, Ozel E, Attar N, Ozge Bicer C. Influence of different conditioning methods on the shear bond strength of novel lightcuring nano-ionomer restorative to enamel and dentin. Lasers Med Sci. 2010;25(6):861-6. 34 Moshaverinia A, Roohpour N, Rehman IU. Synthesis and characterization of a novel fast-set proline-derivative-containing glass ionomer cement with enhanced mechanical properties. Acta Biomater. 2009;5(1):498-507. 35 Culbertson BM. New polymeric materials for use in glass-ionomer www.ineedce.com

cements. J Dent. 2006;34(8):556-65. 36 Moshaverinia A, Ansari S, Moshaverinia M, Roohpour N, Darr JA, Rehman I. Effects of incorporation of hydroxyapatite and fluoroapatite nanobioceramics into conventional glass ionomer cements (GIC). Acta Biomater. 2008;4(2):432-40. 37 Xu HH, Eichmiller FC, Antonucci JM, Schumacher GE, Ives LK. Dental resin composites containing ceramic whiskers and precured glass ionomer particles. Dent Mater. 2000;16(5):356-63. 38 Xie D, Chung ID, Wu W, Mays J. Synthesis and evaluation of HEMA-free glass-ionomer cements for dental applications. Dent Mater. 2004;20(5):470-8. 39 Coutinho E, Van Landuyt K, De Munck J, Poitevin A, Yoshida Y, Inoue S, Peumans M, Suzuki K, Lambrechts P, Van Meerbeek B. Development of a self-etch adhesive for resin-modified glass ionomers. J Dent Res. 2006;85(4):349-53. 40 Behr M, Rosentritt M, Loher H, Kolbeck C, Trempler C, Stemplinger B, Kopzon V, Handel G. Changes of cement properties caused by mixing errors: the therapeutic range of different cement types. Dent Mater. 2008;24(9):1187-93. 41 Behr M, Rosentritt M, Loher H, Handel G. Effect of variations from the recommended powder/liquid ratio on some properties of resinmodified cements. Acta Odontol Scand. 2006;64(4):214-20. 42 Dowling AH, Fleming GJ. Are encapsulated anterior glass-ionomer restoratives better than their hand-mixed equivalents? J Dent. 2009;37(2):133-40. Online Completion

Lou Graham, DDS Dr. Lou Graham is a graduate of Emory Dental School. He is the past Dental Director at the University of Chicago and currently holds a part-time faculty position there. Dr. Graham is an internationally recognized lecturer involved in continuing education that focuses on incorporating current clinical advancements through conservative dentistry. Dr. Graham practices full time in Chicago, IL.

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Questions
1. As researchers investigated various materials, 7. Microfilled composites offer _______. a. the ability to polish the composite to a high gloss two main categories of direct tooth-colored b. the ability to retain a high gloss restorations evolved; these were _______.
a. b. c. d. composite resins and silicates silicates and glass ionomer cements composite resins and glass ionomer cements acrylics and silicates c. superior esthetics d. all of the above

13. The strength of glass ionomers was improved through the addition of _______.
a. b. c. d. methacrylate monomer polymer containing free radical double bonds compomer particles none of the above

2. The monomer-based content in composite resins is typically _______.

a. b. c. d. bis-GMA TEGDMA DMA any of the above

8. _______ is a fundamental component of glass ionomer cements.

a. b. c. d. Fluoroaluminosilicate glass Polyalkenoic (or polyacrylic) acid Resin a and b

14. The monomer in resin-modified glass ionomers _______.

3. Setting of composite resins _______.

a. occurs through polymerization of the monomers b. results in the fillers being dispersed in the set polymer c. occurs through an acid-based reaction d. a and b a. b. c. d. low strength a high degree of polymerization shrinkage a high level of shrinkage stress all of the above

9. The inclusion of water in glass ionomers and their hydrophilicity results in _______.
a. b. c. d. wet contact with the tooth surface a weak bond over time a strong bond over time a and c

a. cross-links b. sets through polymerization when light-activated c. does not interfere with the acid-based setting reaction d. all of the above

15. The direct bonding to the tooth structure observed with glass ionomers was found in one study to be attributable to _______.
a. b. c. d. bonding of the gel phase around the hydroxyapatite the hybrid layer monomer a and b

4. Early composite resins exhibited _______.

10. The setting reaction for glass ionomers is _______.

a. b. c. d. a. b. c. d. acid-based alkali-based ploymerization-based none of the above

5. The current range of composite resin restoratives offers the _______ of all direct tooth-colored materials.
a. b. c. d. a. b. c. d. greatest strength and wear resistance lowest strength and wear resistance greatest strength and poorest esthetics none of the above contain iodide contain fluoride do not contain fluoride a and b

11. Glass ionomer cements _______.

tolerate moist environments adhere directly to the tooth structure are applied to moist tooth surfaces all of the above

16. Following Er:YAG laser-irradiation of dentin, _______ has been observed with the use of glass ionomers.
a. b. c. d. a deeper hybrid layer no hybrid layer no setting reaction a and c

6. Composites typically _______.

12. In the quest for a single material that might meet all requirements for the ideal restorative, _______have evolved.
a. b. c. d. composites acrylics glass ionomer cements a and c

17. The use of glass ionomer conditioner is important for _______ in bur-cut dentin.
a. b. c. d. microtensile bond strength shrinkage stress reduction all of the above

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Questions
18. Metal-reinforced glass ionomers _______.
a. b. c. d.

typically include silver-based alloys in the mix are used primarily for core buildups can be used to restore primary molars all of the above

29. The introduction of nanotechnology _______.

a. b. c. d. occurred initially in composites heralded improved esthetics did not compromise strength all of the above

40. The use of phosphoric acid has been found to provide the greatest bond strength to _______.
a. b. c. d. enamel dentin cementum a and c

19. The cermet _______ .

a. results from fusing metal ions to fluoroaluminosilicate glass particles b. is a subset of metal-reinforced glass ionomers c. releases less fluoride than other glass ionomers d. all of the above

30. Nanofilled composite resins were designed to combine the _______.

41. Nano-ionomer has been found to ______.

a. have compressive strength at least equal to glass ionomers b. have good flexural and diametral tensile strength c. be less brittle than resin-modified glass ionomers d. all of the above

20. Compomers are also known as _______.

a. b. c. d. polyacid-modified glass ionomers polyacid-modified acrylics polyacid-modified composites none of the above

a. polishability and esthetics of microfilled composites b. strength and wear resistance of microhybrid composites c. strength and wear resistance of compomers d. a and b a. b. c. d. improve the translucency of composites improve the opalescence of composites make composites more natural looking all of the above

31. Nanofillers in composites _______.

42. Experimentally, the inclusion of a methacryloyl derivative of l-proline in glass ionomers was found to result in _______.
a. b. c. d. greater strength greater polishability lower reflectance all of the above

21. Compomers contain _______.

a. filler similar to the glass particles contained in glass ionomers b. dimethacrylate monomer and polyacid c. no water d. all of the above

32. Nanofilled composites offer _______ microfilled composites.

a. b. c. d. improved strength compared to reduced strength compared to the same strength as none of the above

43. Self-etch adhesives to further strengthen adhesion to tooth structure have been researched for _______.
a. b. c. d. a. b. c. d. composites gold inlays resin-modified glass ionomers a and c were weak consisted of two pastes were hand-mixed all of the above

22. Setting of compomers occurs through _______.

a. b. c. d. polymerization only an acid-based reaction only both polymerization and an acid-based reaction none of the above

33. The addition of pre-polymerized nanofillers forming nanoclusters has been found to _______ in composites.
a. b. c. d. a. b. c. d. reduce polymerization shrinkage increase shrinkage stress increase strength a and c Water and polycarboxylic acid Nanofillers Reactive resins all of the above

44. Early composites ______.

23. It has been found that _______ with the methacrylate-based polymer molecules is due to dilution of filler particles through the presence of water.
a. b. c. d. the release of metal ions that hydrate the release of metal ions that chelate the release of carboxyl bonds that chelate all of the above

34. _______ are contained in nano-ionomers.

45. _______ is an option for the handling and application of composite.

a. A multi-dose syringe with a mixing pad b. Direct application from a unit-dose capsule c. Use of a disposable tip and multi-dose syringe for flowables d. all of the above

35. The nanofillers in nano-ionomer are based on _______.

a. b. c. d. silica and phosphate zirconia and phosphate fluoride and zirconia zirconia and silica

46. The use of _______ is an option for mixing glass ionomers.

a. b. c. d. a powder and liquid a capsule a Paste Pak all of the above

24. Compomers have _______ compared to composites.

a. b. c. d. lower compressive and flexural strength a lower modulus of elasticity less resistance to fracture and wear all of the above

36. Nano-ionomer contains _______ fluoroaluminosilicate glass particles.

a. b. c. d. 17% 27% 37% none of the above

25. There have been concerns about the release of _______ from compomers.
a. b. c. d. fluoride EDTA HEMA b and c

47. Measuring and mixing errors can result in incorrect ratios of two-component materials and can lead to _______.
a. b. c. d. reduced strength reduced surface hardness reduced fracture resistance all of the above

37. Primer must be used prior to placement of nano-ionomers to optimize _______.

a. b. c. d. compressive strength tensile shear bond strength flexural strength all of the above

26. Biofilm formation is significant on _______.

a. b. c. d. a. b. c. d. a. b. c. d. compomers amalgam composites a and c

48. Using premeasured unit dosing with mixing occurring as the material is extruded can _______.
a. b. c. d. save time provide ease of use increase waste a and b

38. _______ studied the shear bond strength of nano-ionomer to enamel and dentin.
a. b. c. d. Korovsky et al Korkmaz et al Korbovskia et al none of the above

27. A giomer contains _______.

milled, silanized glass ionomer fillers a composite resin base a silicate base a and b the strength of composites the esthetics of composites been shown to release fluoride all of the above

49. Researchers in one investigation on the mixing of glass ionomers advocated the use of _______.
a. b. c. d. powder and liquid precapsulated unit doses a dual paste system none of the above

28. Giomers have _______.

39. The use of only primer has been found to result in the greatest shear bond strength 50. The _______ is a factor when selecting a to _______. tooth-colored restorative.
a. b. c. d. enamel dentin cementum a and b a. b. c. d. requirements for the patient gender of the patient individual restoration a and c

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ANSWER SHEET

Advances in Tooth-Colored Restorations

Name: Address: City: Telephone: Home ( ) Title: E-mail: State: ZIP: Country: Lic. Renewal Date: Specialty:

Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

Educational Objectives
1. Describe the early tooth-colored direct restorative materials 2. List and compare the attributes of composite resins and glass ionomer cements 3. Describe the composition of a compomer, and compare it to composite resins and conventional glass ionomers 4. Describe the restoratives containing nanotechnology and the effect of nanotechnology in nano-ionomer restorations

For immediate results, go to www.ineedce.com to take tests online. answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619.  ayment of $59.00 is enclosed. P (Checks and credit cards are accepted.) If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: ______________________________ Exp. Date: _____________________ Charges on your statement will show up as PennWell 0 0 0 0 0 0

Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 1. Were the individual course objectives met? Objective #1: Yes No Objective #2: Yes No 2. To what extent were the course objectives accomplished overall? 3. Please rate your personal mastery of the course objectives. 4. How would you rate the objectives and educational methods? 5. How do you rate the authors grasp of the topic? 6. Please rate the instructors effectiveness. 5 5 5 5 5 5 4 4 4 4 4 4 Yes Yes Objective #3: Yes No Objective #4: Yes No 3 3 3 3 3 3 2 2 2 2 2 2 No No 1 1 1 1 1 1

7. Was the overall administration of the course effective? 8. Do you feel that the references were adequate?

9. Would you participate in a similar program on a different topic?

10. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________ 11. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________ 12. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________ If not taking online, mail completed answer sheet to

Academy of Dental Therapeutics and Stomatology,

A Division of PennWell Corp.

P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER The author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant from 3M ESPE. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@ pennwell.com. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50.
AGD Code 253, 017

COURSE CREDITS/COST All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $49.00 to $110.00. Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANBs annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANBs Recertification Department at 1-800-FOR-DANB, ext. 445.

RECORD KEEPING PennWell maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. 2010 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

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