Dent 5801 Operative Dentistry I

Oct 9th, 2007

Daranee Versluis-Tantbirojn
Division of Operative Dentistry
Department of Restorative Sciences
 Students will be able to

 Understand clinical behavior of glass-ionomers from

the material viewpoint

 Apply scientific information from the literature for

clinical decisions about the use of glass-ionomers

 Appropriately use glass-ionomers in restorative

dentistry
 DENT 5351 Dental cements, Dr. Combe, Feb 2, 2007

A-B dental cements Zinc oxide-

eugenol
cement (‘ZOE’)

Zinc Zinc
polycarboxylate
phosphate EUG cement (‘ZPO’)
cement
(‘ZPH’)
ZnO
polyacrylic + pendant methacrylate groups
PHA acid
Silicate Fluoroalumino Glass-ionomer
cement silicate glass cement (‘G-IC’)

Resin-modified
glass-ionomer
polyalkenoic acids + calcium fluoroalumino silicate glass + methacrylate
copolymer
Siliceous hydrogel
Conventional GIs
Glass Ca2+
(Acid-based reaction)
CO-O- CO-O-
core F
-
Ca2+

Tooth structure
F
- PO43- Ca2+ = initial set
Ca2+ CO-O- (minutes)
CO-O- Ca2+
Ca2+
-O-CO Al3+ CO-O- -O-CO Al3+ PO43-
Al3+ = final set
Ca2+
CO-O-
2+
(days, weeks, months)
CO-O- Ca
-
F
CO-O-
CO-O- Al3+
PO43- Resin-modified GIs
CO-O- Al3+ - Al3+
F Ca2+ Ca2+
Light initiated or
- CO-O- CO-O-
F
PO43- autocure (set w/o
light)
methacrylate Ca/Al polyacrylate
copolymer Drawing adapted from
matrix
(resin-modified GI) Albers HF 1996, Tooth-color Restoratives.
 True glass ionomers

Conventional
or ‘self-cured’
Resin-modified
‘light-cured’

acid-base reaction

Mixing
Cure in the dark
 (Bowen 1963) (Wilson & Kent 1972)

Resin composite Glass ionomer

cement

Polyacid-modified
composite (compomer) Resin-modified GI

‘Giomer
’
‘Hybrid ionomer composite’
(Geristore) True glass ionomers
Glass ionomers in restorative dentistry
 Glass ionomers in restorative dentistry

*
Fuji II LC
Fuji IX
*
Ketac Molar
Ketac Fil

Vitrebond

* Ketac Bond
Vitrebond Plus *
Fuji Lining

RelyX Luting

* FujiPlus
RelyX Luting Plus

FujiCem *
* presently used in Operative preclinic & clinic
 Ion exchange layer

Glass Ca2+ • Adhesion to tooth

CO-O- CO-O-
core F
-
Ca2+ structures

Tooth structure
-
F PO43-
Ca2+ CO-O-
CO-O- Ca2+
• Release ions (F-)
Ca2+
-O-CO Al3+ CO-O- -O-CO Al3+ PO 3-
affect balance
4
CO-O-
Ca2+ CO-O- Ca
2+ between de/remin
-
F
CO-O- Al3+
CO-O- Al3+
CO-O-
F
- Al3+
Ca2+
PO43-
Ca2+
• ‘Non-irritant’
- CO-O- CO-O-

• Translucent
F
PO43-

• Better mechanical
Compare with other cements properties
 Glass ionomers: Use with caution

Inadequate physical properties *

Sensitive to water gain/loss *

Esthetic compromise *

Anticaries property is questioned

Adhesion property is not comparable to

composite + dentin adhesive

* More crucial if used as a permanent filling material

GIs cannot be used as permanent restorative material
in stress-bearing areas

Major physical failure

58 months
Bulk fracture
Marginal fracture
Poor anatomic form (wear)
Dissolution/disintegration
Clinical failure of class-II restorations of a highly viscous glass-ionomer
material over a 6-year period: A retrospective study
Scholtanus JD, Huysmans MCDNJM
Esthetic compromise J Dent 2007;35:156-62

Opaque
Surface finish
 Use with cautions

Sensitive to water gain/loss

Maintain water balance during initial setting

Resin-modified GI restoratives (GC Fuji II LC)

Resin protects cement from water

Fast-set GIs (GC Fuji IX)

Wait 3-6 min before polishing

Polish with water coolant to prevent dehydration

Apply unfilled resin to protect surface

 Anticaries property is questioned?

In vitro anticariogenic potential of GIs is known

Plaque or acid medium

Vitrebond Plus/Z250 Z250

Adapted from Hicks
 Anticaries property
Questionable?

A systemic review shows no overall evidence for or against a treatment

effect of inhibition of secondary caries by glass ionomer restoration

28 studies from 1970 to 1996; total of 3965 participants; high caries risk
5 positive studies
No secondary caries in GI; secondary caries in control
19 neutral studies
No secondary caries in either group
or secondary caries present in both groups
4 negative studies
Secondary caries in GI; no secondary caries in control

Randall RC, Wilson NH. J Dent Res 1999;78:628-637

How would the data apply to present glass ionomers?

 Anticaries property
Questionable?
Glass ionomers reduce recurrent caries in high-risk patients
who do not routinely use topical fluoride.

Restorations in xerostomic patients: composite or amalgam vs GI

Patients were instructed to use NaF gel daily

At 2 years recall:
No recurrent caries was found in the fluoride users
No recurrent caries associated with conventional GI
In fluoride non-users, 8 composite and 1 RMGI had recurrent caries
& higher incidence of caries at amalgam cavosurface margins

McComb D, Erickson RL, Maxymiw WG, Wood RE

Operative Dentistry 2002;27:430-7

Haveman CW, Summitt JB, Burgess JO, Carlson K

JADA 2003;134:177-84
 Use GI restorative material for caries control

G. Mount

67 Cl V composite and 65 Cl V glass ionomer cement

After 5 years, 1% of glass ionomer and 6% of composite restorations

had become carious

Approximately twice as much marginal staining around the composite

as around the glass ionomers.

Tyas MJ. Australian Dental Journal 1991; 36:236-9.

Cariostatic effect of glass ionomer cement: a five-year clinical study.
 Adhesion property of glass ionomers

Bond strength (MPa)* Enamel Dentin

GI Restorative ~ 4-14 ~ 4-10

Composite + adhesive ~ 30 ~ 25
GI liner ~ 3-7 ~ 4-10

GI luting cement ~ 6-10 ~ 2-6

Metal Porcelain
GI luting cement ~ 7-12 (sandblast) ~ 8-14 (Zr, Alumina)

Resin cement ~ 15-25 ~ 25 (etched porcelain

+ adhesive & ceramic primer)

* Shear mode; 3M and GC products; 3M Product Profiles

Bond strengths of glass ionomers are not comparable
to composite + adhesive or resin cement

Should I use GI luting cement or resin cement?

Should I use GI restorative or composite?

Should I use GI liner or not?

What are the most likely errors that affect adhesion?

Other issues to consider related to adhesion:

post-operative sensitivity
microleakage
pulp protection
 GI luting vs Resin cement

Post-operative sensitivity was a problem with GI lutings in

1980’s–1990’s

Studies showed that GI lutings did not cause post-op sensitivity.

No differences between GICs (conventional & resin-modified) or a zinc

phosphate luting cement
Kern M, Kleimeier B, Schaller HG, Strub JR. J Prosthet Dent 1996;75:159-62
Jokstad A. Int J Prosth 2004;17:411-6

Paste-paste resin-modified GI luting cement did not cause post-

operative sensitivity (290 restorations in 268 patients) .
Yoneda S, Morigami M, Sugizaki J, Yamada T. Quintessence Int. 2005;36:49-53

The level of tooth sensitivity post-cementation (1-4 wks) was less

than pre-operatively in both conventional and resin-modified GICs.
Smales RJ, Gale MS. Oper Dent 2002;27:442-6
 GI luting vs Resin cement

Post-operative sensitivity was a problem with GI because:

Dentin was desiccated

Anhydrous glass ionomer cement

Should I use GI luting cement or resin cement?

GI luting cement for indirect metal restoration

(inlays, onlays, full gold crown) and PFM.
Simple application & easy clean up

Resin cement for esthetic indirect restorations

(porcelain, ceramics, indirect composite) and
indirect metal or PFM where additional retention
is required (minimal tooth structure).
Example of instruction for use of a resin-modified glass-
ionomer luting cement (3M RelyX Luting Plus)

 Pulp protection if necessary

 Clean tooth, rinse and lightly dry
leaving tooth surface moist.

Remove excess cement

Mix with spatula for 20 second
at a waxy stage (after 2
Working time 2.5 minutes
minutes from placement)
 Should I use GI restorative or composite?

Clinical studies showed mixed results in Cl V retention

% Retention Composite RMGI References

3 years 86 55 Folwaczny et al., 2001
2 years 81 96 Brackett et al., 2003
2 years 70 100 Onal and Pamir, 2005

However, deficiencies in color stability, anatomic form, or wear

limit the longevity of glass ionomer restorations.

Post-operative sensitivity of composite restorations

Polymerization shrinkage
Microleakage
Sub-optimal bonding
 Post-operative sensitivity
Composite leakage
& Post-op sensitivity

Anecdote:
No sensitivity after
replacing composite
with glass ionomer
restoration

Painful
on pressure
Example of resin-modified glass-ionomer restorative
(GC Fuji II LC)

Cavity conditioner (recommended for GC products)

 Enhanced bonding by removing smear layer
 Mild (25%) polyacrylic acid
 Apply 10 seconds on dentin and enamel,
rinse, blot. Surfaces should appear moist
(glistening) before applying glass ionomer
 Should I use GI liner?

Bond strength (MPa)* Enamel Dentin

Composite + adhesive ~ 30 ~ 25
GI liner ~ 3-7 ~ 4-10

Bond strength of GI liner is not comparable to composite

However, GI liners prevent post-operative sensitivity.

When GI liner (e.g., Vitrebond or Fuji Lining Cement) is applied to the

deepest portions of Class I, II, and V tooth preparations before any
bonding systems are used, clinicians have reported that it almost
totally prevents postoperative tooth sensitivity.

Gordon J Christensen, JADA 2002;133:229-231.

 Should I use GI liner?
Less microleakage with GI liners
Class II amalgam restorations with GI liners had significantly less
microleakage than did restorations with calcium hydroxide liners
or dentin alone (without GI).

Rabchinsky J, Donly KJ. Int J Perio Rest Dent 1993;13:378-83

Marchiori S et al., Quintessence Int 1998;29:637-42

‘Dycal’ should always be covered with GI liner

Ca(OH)2 liner adversely affects bonding efficacy of dentin adhesive

Krejci I, Lutz F, J Dent 1990;18:263-70

Ca(OH)2 liners ‘wash out’ leaving a void underneath the restoration

Novickas D, Fiocca VL, Grajower R, Oper Dent 1989;14:33-9

How good is Dycal to withstand amalgam condensation?

 Should I use GI liner?

Do not use RMGI when pulp is exposed.

When in direct contact with exposed pulp,

Vitrebond triggered a persistent inflammatory reaction.
Am J Dent 2000;13:28-34
do Nascimento AB, Fontana UF, Teixeira HM, Costa CA
Biocompatibility of a RMGIC applied as pulp capping in human teeth

But GI liner is better than dentin adhesive in deep cavity.

Pulp response in deep class V composite restoration lined with
Vitrebond was better than total-etched adhesive.
Dent Mater 2003;19:739-46
Costa CA, Giro EM, do Nascimento AB, Teixeira HM, Hebling J
Short-term evaluation of the pulpo-dentin complex response to a resin-modified glass-ionomer cement
and a bonding agent applied in deep cavities.
 How deep is deep?

~ 1 mm below DEJ* 1-2 mm from pulp* 0.5-1 mm from pulp*

>1 mm from DEJ* (‘pinkish’)

GI liner optional GI liner Dycal

Etch & Adhesive Etch & Adhesive GI liner

Composite Composite Etch & Adhesive

* The numbers are arbitrary for illustration purposes. Composite

It depends on the tooth, location, pulp recession, etc.
 Example of resin-modified glass-
ionomer liner (3M Vitrebond Plus)

Use clean
Dycal carrier

Followed by etching, bonding, filling