Direct esthetic restorative materials

Glass ionomer cements

DEFINITION
Self-cured, tooth colored, fluoride releasing restorative materials that bond to tooth structure without an additional bonding agent.

CLASSIFICATION
Luting agents Restorative material (erosion/abrasion lesions in permanent dentition, and restorations in primary teeth) Liners and bases Core build-up materials Pit and fissure sealants

Composition
Main components are: Glass Polyacid Water Tartaric acid Different types and combinations of polyacid and glass create different versions of GIC
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Glass
Three main components:
Silica SiO2 Alumina Al2O3 Calcium fluoride CaF2 In addition to sodium and aluminium fluorides, and calcium or aluminum phosphates. Components are fused at high temperatures, shock cooled then ground to a powder. Particle size depends on application
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Liquid
Liquid: co-polymers of polyacrylic acid and water E.g. of copolymers used:
Acrylic acid and itaconic acid Acrylic acid and maleic acid

Viscosity of the liquid depends on molecular weight and polyacid concentration. Tartaric acid influences working ad setting time

Ref. Introduction to dental materials

DISPENSING
2 bottle system hand mixed:
Powder Liquid

Anhydrous cement: powder (glass and freeze dried polyacid) and distilled water Capsules (pre-measured powder and liquid) mixed using a triturator (mixer). Easy to use, GIC is directly dispensed into cavity, eliminate errors from manual mixing.
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Ref. Phillips science of dental materials

Setting reaction
Acid base reaction. Three overlapping steps:
Dissolution Gelation Hardening

SETTING REACTION
Powder and liquid are mixed: Calcium, aluminium and fluoride from the glass particles released Calcium will cross-link the polyacrylic acid chains. Calcium will be gradually replaced by aluminium over the next 24 hours.
Role of water? Role of sodium and fluoride?
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Continue,
Gelation of cement: 2-3 minutes after mixing, cannot be manipulated. Next minute, the material hardens, but setting and maturation goes on for several hours. Finishing is postponed until after 24 hours
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releases calcium, aluminum, sodium and fluoride. All is left is silica gel. Gelation: free calcium react first with carboxyl groups in the acid leading to initial setting. At this stage contamination from outer environment may lead to: Loss of aluminum ions Water loss The end result is a weak unaesthetic material
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Dissolution: Acid attacks the glass. This

Continue
Hardening: can take as long as 7 days. Aluminum ions provide the final strength of the matrix (aluminum salt bridges). In addition, water is bound to silica gel. End result: glass particles each surrounded by silica gel in a matrix of crosslinked polyacrylic acid

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SETTING OF GIC

Ref. Introduction to dental materials

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Properties
Handling characteristics: previous versions of GIC had problems with inappropriate working and setting time. Tartaric acid inclusion resulted in:
Tartaric acid reacting with calcium as it was released which extends working time to reasonable values Enhances rate of formation of aluminum polyacrylate crosslinks which speeds up setting.
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Properties
Adhesion: Chemical bond to enamel &dentine by ion
exchange (displacing calcium and phosphate ions and creating an intermediate layer of polyacrylate, phosphate and calcium. Or binding with Ca+2 in tooth.

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Continue,
Adhesion: bond to dentine maybe by hydrogen bond to collagen and ionic bond to apatite crystals in dentine. The major type of failure is cohesive within GIC rather than adhesive with tooth surface. so, GIC has a low tensile strength (brittle) To obtain a good bond: tooth surface should be cleaned, treated with conditioner to remove debris and improve wettability

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Properties
Aesthetics: glass governs the color of the material. Pigments maybe added such as carbon black, ferric oxide. The major issue is translucency rather than color. GIC translucency is more comparable to dentine. Aesthetically, GIC is inferior to composite, appear opaque, dull, lifeless
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Properties
Solubility: Sensitive to moisture
&dehydration during setting and maturation (1st 24 hours). Use varnish (MMA resin, nitrocellulose) finishing after 24 hours Loss of material from GIC maybe due to:
Dissolution of immature cement Abrasion (GIC have low abrasion resistance) Erosion

Loss of material decreases after it fully sets which usually takes a few days
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Properties
then lower continuous release for long time. Fantibacterial, remineralization Biocompatibility: Tolerated by surrounding tissue & kind to pulp. However, theyve been associated with postoperative sensitivity, acid pH initially then neutral

Fluoride release: high initial fluoride release,

Strength: Moderate compressive strength, low tensile Thermal expansion: similar to that of tooth Effect of P:L on strength and solubility?
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strength. not suitable for stress bearing areas

structure

Clinical application of GIC

General notes:
Tooth surface should be clean and dry but not desiccated Polyacrylic acid should be used if advised by manufacturer GIC should be protected with a varnish (resin dissolved in a volatile solvent) to avoid moisture contamination and dehydration

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CLINICAL USE
Luting cements:
Advantages:
Fluoride release Low film thickness Kind to pulp Bond to tooth structure

Their use decreased after hybrid ionomers and resin cements were introduced since they are stronger
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CLINICAL USE
Restorative materials: used in non-stress bearing areas:
Root caries Occlusal lesions in primary teeth Temporary restorations Cervical cavities (abrasion and erosion lesions) Anterior class III when color matching is not an issue

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CLINIAL USE
Liners and bases: used to protect the pulp from:
Temperature changes Chemicals from other restorative materials Acid etchants

Liners have lower powder: liquid ratio and weak. GIC bases are used to rebuild missing tooth structure, stronger than liners and have a higher powder: liquid ratio

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Ref. Phillips science of dental materials

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Clinical application
Cavity preparation: conservative, no undercuts necessary due to chemical adhesion quality. Isolation: careful and proper isolation is necessary. Blood and saliva may impair setting, weaken GIC and lower bond strength to tooth structure and reduce aesthetics
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Clinical application
Preparation of dentinal surface
Depends on the nature of the tooth surface on which GIC will be placed. Most importantly, clean surface, use of a conditioner Incase of prepared cavities: no need for cleaning with pumice and water but a conditioner is needed to remove smear layer. Patients with sensitive teeth?
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Clinical application
Pulpal protection: maybe necessary in very deep cavities, to prevent direct contact between GIC with pulp tissue. The liner of choice is calcium hydroxide, but keep in mind that the maximum area of dentine is needed to ensure good bond with GIC.

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Clinical application
Dispensing, mixing, insertion:
For powder liquid system: ensure accurate ratio, and tap powder bottle to loosen up the particles. Gradual incorporation of powder into liquid, and follow manufacturer instructions in terms of mixing time. Encapsulated: capsule should be shaken first, then mixed in an amalgamator running at 4000 rpm for 10 seconds
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Clinical application
Finishing and polishing: a matrix maybe used
to protect the surface until the material sets, then any excess GIC should be removed after 24 hours by finishing and polishing. Removal of gross excess maybe done using a sharp blade rather than a carver. As a general rule: finishing should be delayed After 24 hours: using fine diamond bur or 12 blade carbide bur with water. Polishing is done using abrasive discs again with water.
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Clinical application
Surface protection: varnishes used:
Solution of natural copal resin Synthetic resin (cellulose acetate)

These two maybe dissolved in an organic solvent such as ether, acetone, chloroform Other varnishes: nail varnish, bonding agents.

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CLINICAL USE
Lamination or sandwich technique: GIC is used as a base underneath composite restorations, in deep proximal cavities where the gingival floor is on the root. GIC in this case provides better seal and releases fluoride.

Ref. Dental materials, clinical applications.

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Silver cermets
Have metal particles added to them, e.g. silver (particle size 3-4 m) , to improve toughness strength and abrasion resistance. Also contain Titanium oxide. Liquid is copolymer of acrylic, maleic and 9% tartaric acid Presentation:
Powder liquid system, or capsules

Clinical use: small occlusal cavities

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CLINICAL USE
Core build up materials: cermet GICs are usually used for this purpose. They are used:
In locations were esthetics are not important To replace missing tooth structure where the permanent restoration is crown.

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Ref. Phillips science of dental materials

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CLINICAL USE (Reference, Dental

materials, clinical applications for dental assistants and dental hygienists, chapter 7)

Pit and fissure sealants: materials used to seal noncarious pits and fissures of deciduous and permanent teeth.

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Indications for the use of sealants

Teeth with deep pits and fissures. Sealants are targeted to young children so that susceptible pits and fissures are protected. High caries risk patients (poor oral hygiene, high sugar intake, etc)
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Types of sealants
GIC based Resin based sealants:
similar composition to resin composite (based on Bis-GMA or UDMA) Maybe self cure (Two components) or light cure (One component) Maybe clear, opaque or tooth colored

Sealants are not as heavily filled as resin composite, because they would be too viscous
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Continue,
The use of GICs as sealants have been suggested due to: Fluoride release. Adhesion to moist tooth structure Disadvantages: Inability to fully penetrate fissures Brittleness Low wear resistance
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Clinical application
The tooth should be isolated and 20%polyacrylic acid is applied for 10-15 seconds (or according to manufacturer instructions. GIC is mixed and applied to pits and fissures. GIC varnish is applied to protect the sealant from moisture contamination and dehydration. Occlusion is checked and adjusted.
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Hybrid (resin-modified) GIC

Hydroxyethyl methacrylate (HEMA) resin, is added to GIC to improve physical properties. Advantages compared to conventional GIC:
Improved wear resistance Stronger More polishable Resin protects the matrix from moisture, which decreases solubility Setting reaction?

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Resin-modified GIC
Composition: the liquid component:
Hydrophilic monomer is added to the liquid polyacrylic acid (HEMA) or Polyacrylic acid with pendent methacryloxy groups,

In addition to tartaric acid and photoinitiator

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Setting reaction
Prolonged and slow acid-base reaction. This will prolong working time. Rapid set is provided by light curing. If the material is not exposed to light it will eventually set by acid base reaction in 15 minutes. Incremental placement maybe necessary, issues of polymerization shrinkage maybe encountered.
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Properties
Long working time and short setting time Finishing and polishing maybe done immediately More resistance to acid attack and dehydration

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Clinical applications
Direct restorative materials, proved to be better than conventional GICs in primary dentition Liners and bases underneath composites, amalgams Luting agents

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Ref. Phillips science of dental materials

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