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Conference Paper
Glass lonomer Restorative Cement Systems: An UpdateJ o e l H . B e r g , D D S , M S ' • T h e o d o r e P. C r o l l , D D S 2
Abstrac t: Glass ionomer cements have been used in pediatric restorative dentistry for more than two decades. Their usefulness in clinical dentistry
is preferen tial to oth er materials because o f fluoride release fro m the glass component, biocomp atibility, chemical adhesion to dentin and enamel,
coefficient of therm al expansion similar to tha t o f tooth structure, and versatility. The purpose of this paper was to review the uses of glass
ionom er materials in p ediatric dentistry, specifically as p it and fissure sealants, dentin and enam el replacement repair materials, and luting cements,
and fo r use in glass ionomer/resin-based composite stra tificat ion too th res torat ion (the sandwich technique). This article can also be used as a
guide to research and clinical references regarding specific aspects o f the glass ionom er systems and ho w they are used fo r young patients.
(Pediatr Dent 20l5;37(2):li6-24)
K E Y W O R D S : G L A S S IO N O M E R C E M E N T , P E D IA T R IC R E S T O R AT IV E D E N T IS T R Y
This paper reports on the November 2014 American Academyof Pediatric Dentistry restorative dentistry consensus conferenceregarding the clinical use of glass polyalkenoate (glass ionomer)materials in children. Compared to other dental restorative andluting materials, none combine so many advantages with so fewdisadvantages. The various formulations of the glass ionomersystems make for unprecedented versatility and clinical effective-ness. Restorative objectives for children include sealing noncarious pits and fissures, rendering the tooth and the tooth/restoration interface caries resistant after tooth repair, providingeasy handling properties for the dentist and assistant, and keep-ing material costs reasonable. In addition, the material selectedfor the procedure must endure the grueling intraoral environ-ment, without degradation, for as long as possible. Certain glassionomer systems meet those objectives remarkably well andhave become a standard of care in a variety of clinical applica-tions for children.
For the education of both children and parents, Croll de-fined glass ionomers as “a type of filling material that bonds toteeth...”1because glass ionomers are selfadhesive materials2andare the only commonly used materials that chemically bondto tooth structure.3,4Thanks to continuing improvements in
products over the years, this category of products has gainedan extremely important role in modern clinical dentistry.
The purpose of this paper was to review the uses of glass
ionomer materials in pediatric dentistry, specifically as pit andfissure sealants, dentin and enamel replacement repair materials,and luting cements, and for use in glass ionomer/resinbasedcomposite stratification tooth restoration (the sandwich tech-nique). This article can also be used as a guide to research andclinical references regarding specific aspects of the glass ionomersystems and how they are used for young patients.
'Dr. Berg is Dean. University of Washington School of Dentistry, Seattle, Wash., U.S.A.
2 Dr. Croll is a pediatric dentist in private practice, Doylestown, Pa., U.S.A.; an affili
ate professor. Department of Pediatric Dentistry, University of Washington School of Den
tistry': and an adjunct professor, pediatric dentistry. School of Dentistry. University of Texas Health Science Center at San Antonio, San Antonio, Texas, U.S.A.
Correspond with Dr. Berg at joelberg@uw.edu
Background
Glass polyalkenoate cements, more commonly known as glassionomers, are made of calcium or strontium aluminofluorosilicate glass powder (base) combined with a water soluble polymer (acid). Glass ionomers were invented in the UnitedKingdom in 1969, and the earliest formulations became avail-able in the early 1970s. Glass ionomer cement components,when blended together, undergo a hardening reaction thatinvolves neutralization of the acid groups by the powdered glass
base. Significant amounts of fluoride ions are released duringthis reaction, which relies on the presence of water. Two varia-tions of true glass ionomer materials developed in the 1980sand 1990s are those modified by inclusion of metal and thosewith a lightpolymerized liquid resin component that rendersthe cement photocurable as part of the overall hardeningreaction. The latter are called resinmodified glass ionomercements.
The original glass ionomer commercial formulations intro-duced in the 1970s failed to gain widespread interest, especially by dentists in North America. Those materials had long settingtimes, were susceptible to dissolution and desiccation duringhardening, and had poor wear resistance and low fracturestrengths once set. Regardless of the advantages of the first glassionomers—including fluoride ion release and uptake by enameland dentin, coefficients of thermal expansion similar to that of
tooth structure, chemical bonding to both enamel and dentin,tooth color replication, and biocompatibility—dentists did notreadily adopt materials that were difficult to handle and un-reliable in the long term. As time went by, the status of glassionomers changed.
Clinical use o f glass ionomer materials by category
This paper provides a position statement regarding each clinicalindication for glass ionomer materials in children. It is usefulto consider the matter in categories, because different clinicalchallenges require varying solutions, and specific formulations ofglass ionomer materials are used for different clinical purposes.3
Glass ionomer materials, in general, have not approached
the esthetic appearance of resinbased composites (RBCs). How-ever, the resinmodified versions, particularly the nanoionomer,have improved in this regard, but RBCs are still more estheticallydesirable for imperceptible enamel repair of anterior teeth.
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mailto:joelberg@uw.edumailto:joelberg@uw.edu
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Sealants. Glass ionomers have been studied for use as pit
and fissure sealants.6'9 Prior to providing a position statem ent
regarding the use of glass ionomers as sealants, it must be noted
that resin-based sealants are known as the most effective ma
terials for p it and fissure sealan ts.10,11 Bonded resin sealants,
when used properly, work exceptionally well. In the most ex
tensive review of resin sealants in the dental literature, Simonsen
described every aspect of resin-bonded sealants, including:laboratory studies; clinical technique and tooth preparation;
etching time; application of sealants by dental auxiliaries; re
tention of resin sealants and their preventive function; inclusion
of fluoride in the resin, glass ionomer materials used as a
sealant; filler content and color of resin sealants; autocure versus
photopolymerized resin hardening; purposeful sealing of carious
pits or fissures; cost effectiveness; underuse of sealants; and the
controversy about estrogenicity of RBCs and sealants.10Simonsen
pointed out the importance of perfect isolation of a tooth to be
sealed with resin, that the enamel acid etching must be com
pleted with no contam ination of the tooth surface, and that
pits and fissures need to be free of debris so that hidden carious
lesions can be ruled out.
Even though bonded resin sealants are preferred, glass
ionomers offer an alternative and should be considered in cer
tain circumstances, such as:
1. Precooperative children with primary molars having
deeply pitted or fissured surfaces but with teeth that
are difficult to isolate.
2. Permanent first or second molars that are not yet fully
emerged into the mouth, but at-risk pits and fissures
are evident.
3. Co nditio ns whereby a transitio nal sealant can be
considered prior to the placement of a standard long
term resin sealant.
Limitations of glass ionomer sealants include the:1. Physical properties of glass ionomer materials.
2. Specific formulation o f glass ionomer selected for the
procedure.
3. Longevity of glass ionomer cement used as a sealant.
Glass ionomers are brittle materials. Pure (traditional) glass
ionomers, when used as sealants, have been shown to exhibit a
high frequency of fracture within the pits and fissures, although
remnants of the material remain within the depths of the fis
sures as a result of their chemical bond to tooth structure and
some mechanical interlocking retention. Therefore, a preventive
effect remains, probably enhanced by the fluoride component
in the glass. To compensate for the brittleness of traditionalglass ionomers, resin-modified glass ionomer (RMGI) materials
have commonly been selected as alternatives.16'18These materials
offer better physical properties and on-command initial hard
ening by photopolymerization but still lack the flowability and
retentiveness of resin sealants when used on a properly isolated
and acid etch-conditioned tooth surface.
For the primary dentition, there are some indications where
the longevity of glass ionomer as a sealant (especially the light-
hardened resin-modified type) serves adequately until exfoliation
of the tooth. In the permanent dentition, the literature strongly
supports resin sealants as the material of choice for pits and
fissures at risk o f Class I caries.10
Lut ing cement. Glass ionomer cements were first intro
duced as cavity lining materials; soon thereafter, these materials
were used as luting agents. Subsequently, specifically formulated
luting agents have been developed for various purposes.19 Now,
the chief types of luting agents are the powder/liquid formu
lations and resin-modified versions. The resin-modified systems
have dominated in recent years because of their enhanced
physical properties and ease of use.20
Besides differences in physical properties between the tradi
tional chemically hardened glass ionomer luting cements and
the resin-modified types, one needs to remember that theformer requires acid removal of the smear layer for the best
bonding, and the resin-modified materials require a self-etching
adhesive prior to cement application to the tooth surface.
Crown cementation. Since their introduction, glass ionomer
cements have become the material of choice for cementation of
stainless steel crowns and stainless steel orthodontic bands (see
below).20'22 Stainless steel crowns differ from laboratory custom-
fabricated metallic or ceramic crowns, because laboratory processed
crowns have a precision fit. In the stainless steel crown proce
dure, the luting cement acts not only as an interface between
the crown and the tooth, but also as a bulk filler for the voids
that inherently exist under a preformed crown. Therefore, the
clinician is relying on careful contouring, crimping, and finishing
of the crown form, along with adhesive and strength properties
of the cement, for long-term retention o f a steel crown. Precision
laboratory fabricated crowns also require a luting cement that
is practical (i.e., excess is easily removed after crown cementa
tion) and biocompatible, has fluoride ion release and uptake by
dentin and enamel, is adhesive and insoluble in oral fluids, and
has high strengths in thin layers to withstand the daily impact
forces of occlusion and mastication. To a large extent, RMGI
luting cements have satisfied all these requirements for crown
cementation for children and adults.20,21'23'25
Resin luting cements, often selected as luting agents forlaboratory-fabricated permanent tooth crowns, are not preferred
for cementation of stainless steel crowns. They are not self-
adhesive, are less biocompatible with cut dentin, and require amore difficult and time-consuming procedure.
Orthodontic ba nd cementation. Glass ionomers are ideal
for cementing orthodontic bands. Not only are their physical
strengths more than sufficient for that purpose, but the fluoride
ion release and uptake by enamel surfaces protects the teeth
from acid challenge from foodstuffs and from organic acids
produced by biof ilm /plaq ue accumulat ion.22,26'29 No matter
how extensive efforts are to instruct young orthodontic patients
about meticulous oral hygiene, complete daily removal of plaque
and debris, and use of fluoride dentifrices and mouth rinses,
an excellent preventive measure is to have band cement that
releases fluoride and renews itself with fluoride from oral health
care products. Clinicians should know that adhesion of glassionomer luting agents to tooth structure is greater than adhesive
streng ths o f the cements’ internal band surfaces.30 Therefore,
additional retention can be achieved by roughing those metal
surfaces with a diamond bur or employing air particulate
abrasion.31,32
Orthodontic bracket adhesive. Several laboratory studies
have examined the bond strength of orthodontic brackets
bonded to enamel smooth surfaces with glass ionomer cement
when subjected to forces commonly applied to bracket/tooth
interfaces during or thod ontic tooth movem ent.33'35 Although
the bond strength measured with resin-modified varieties has
sometimes been deemed adequate to allow for orthodontic tooth
movement without detachment, these bond strengths are still
significantly lower than those using resin-based bracket ad
hesives. In the same way that resin-bonded sealants out perform
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glass ionomer sealants, resin-bonded brackets have a better
attachment than those with glass ionomer material.36,37
There may be clinical circumstances for which a lower bond
strength bracket adhesive would be desirable. For example, if
brackets were placed for a short term to stabilize an injured
tooth, a RMGI may suffice and decrease the risk of enamel
damage when the brackets are removed. Another example is
when a short-term orthodontic goal is required in a local regionof the mouth and forces involved are minor, a RMGI system
may work well. At least one manufacturer has marketed its
RMGI specifically as an o rthodontic adhesive.38'40 It may be pos
sible to create enhanced formulations of RMGI attachment
cements that could be strong enough to routinely be used as
bracket adhesives, allowing for re tent ion du rin g the entire
duration of orthodontic treatment, act as a fluoride source for
adjacent enamel, and facilitate bracket removal afterwards.41
Cavity liner/base. Glass ionomer products are ideal for use
as dentin replacement protective cavity liners. The fluoride con
tent of these formulations (and associated antimicrobial effect),
chemical bond to dentin, sealing ability, retentiveness, and lack
of postoperative tooth sensitivity make them ideal for internal
use in tooth repair, whether a thin liner or thicker dentin re
placement base is required.42,43 Flowable, low-viscosity versions
of traditional glass ionomer material as well as RMGIs have
been used effectively as cavity liners and bases since the 1970s.44
Glass ionomers provide a simple and effective choice for the
clinician to accomplish all of the objectives of cavity lining
simultaneously.
Dentinal adhesive. Using glass ionomer as a dentinal ad
hesive is a natural extension of the idea that glass ionomers are
ideal cavity liners. By using a glass ionomer material as an ad
hesive on dentin surfaces, above which resin composites are
applied as a surface restorative material, one can accomplish
several restorative objectives simultaneously.45,46 The cavity can
be sealed, the retention of the surface RBC can be achieved,and resistance to further destruction can be avoided. One issue
that must be dealt with when considering using glass ionomer as
an adhesive on dentin surfaces is the enamel margin. Because
the appearance of glass ionomers (even the resin-m odified
variety) still can’t compare to the highly esthetic RBCs, glass
ionomers are best used as an adhesive only for the dentin sur
faces in anterior applications.
Because of the inherent adhesive properties of glass iono
mers and their biocompatibility, RMGIs can be use as adhe
sives in lieu of the sometimes challenging placement of
resin-based adhesives.47,48 It is im po rta nt to remember tha t
the chemical bond of glass ionomers to tooth structure over
time does not hydrolyze the way resin/dentin bonds do.Sandwich technique/dentin replacement. It is perhaps
difficult to distinguish using glass ionomers as liners, dentinal
adhesives, and the sandwich technique.44 The sandwich tech
nique is tissue-specific tooth repair. Also known as stratifica
tion, the sandwich technique simply means that a suitable glass
ionomer (usually the resin-modified type) is used to replace
dentin, and an RBC is overlaid as a bonded enamel replacement.
The glass ionomer is sandwiched between the tooth surface and
the bonded RBC.50 There are a numb er of papers promoting
the use of this technique, with more limited exposure to clinical
testing of the technique with reported outcom es.50 Croll and
Swift reviewed RBC/RMGI stratification, and other writers have
documented the advantages of that restorative approach.51'53Another example of a sandwich-type of technique using
glass ionomers is the tunnel preparation .54,5’ This technique re
quires occlusal preparation and angulated access to the contact
point, wherein glass ionomer is injected to completely fill the
tunnel section, and the occlusal opening is restored with bonded
RBC.
Restorations
The earliest glass ionomers had a slow chemical setting reaction
and were subject to washout or desiccation. Once hardened,their physical properties could not rival those of the RBC. How
ever, the remarkable advantages of the glass ionomer systems
encouraged manufacturers to progress with improvements such
that certain materials became suitable for both dentin and ena
mel replacement.56'59 In the mid 1980s, metal-modified glass
ionomers were introduced; however, although wear resistance
was improved, fracture strengths were not, and the gray color
was an additional disadvantage. In the late 1980s, light-hardened
liners/bases were introduced, followed by RMGI restorative
cements in the early 1990s. Physical properties and handling
characteristics of these resin-modified glass ionomers have made
them a standard restorative material for use in young patients.60
An additional beneficial property of certain RMGI restora
tive cements is triple harde ning .61 Initially, the visible light
beam cures the light sensitive resin, followed by a chemical resin
cure. Then, over an extended period, the glass ionomer acid/base
neutralization reaction matures for additional hardening. Thechemical resin cure is important in times when depth of light
penetration is uncerta in. The early RMGI restorative cements
had such good durability and reliability that several are still on
the market almost 25 years later.62
It should be noted that, even with addition of the light-
hardened resin component, the resin-modified glass ionomer still
maintains the properties and advantages of other glass ionomer
systems. They are hydrophilic and biocompatible, release and
take up fluoride ions, have a coefficient of thermal expansion
similar to that of tooth structure, are tooth colored, and chemically bond to dentin and enamel. No other dental restorative
material has such an array of positive attributes. Wear resis
tance and physical strengths, although much improved from the
original cements (and sufficient for many applications in
primary teeth), still lag behind RBCs.
Glass ionomer materials are excellent for repair of defective
margins of prior restorations and for interim use. For example,
they serve as temporary endodontic access fillings during cal
cium hydroxide apexification or internal tooth bleaching pro
cedures, or as fillings of small marginal defects of RBC or silver
amalgam restorations.
Class I restorations. The C-factor is a way to describe the
effect the number of bonded surfaces have on RBCs as theyshrink during photopolymerization. Such shrinkage is im
portant, as it can open margins during the hardening process.
Because glass ionomers have significantly less shrinkage, their
use for Class I restorations in primary teeth is particularly ad
vantageous.63,64
In the permanent dentition, small, minimally invasive pre
parations can be restored with RMGI; however, if RBC can be
used alone or as an overlay in the stratification method, its
greater wear resistance and fracture strength make it the prefer
able material.65,66
Class I I restorations. For primary molars, RMGI restorative
cement is a good material for small- to medium-sized Class I
restorations.67,68 Traditional glass ionomer material can be used, but preparations must be larger to accommodate a bigger bulk
of cement that is more resistant to fracture.69,70
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Studies have shown excellent results when using RMGI
restorative cement for Class II repair of primary molars.71'82Many
clinicians have abandoned the use of silver amalgam in chil-
dren in favor of RMGIs for tooth repair, which formerly would
have been done with amalgam. By doing so, dentists avoid
explaining the silver appearance of the restoration and also
the ongoing false controversy about mercury in dental filling
material.For permanent teeth, resin composite is still preferred for
Class II direct restorations and the sandwich technique, the
latter for its wear resistance and fracture strength.
Class III restorations. Glass ionomer cement is an ideal
choice for small Class III restorations. The proximal contact
point is a prime location to take advantage o f the unique fluoride-
releasing properties of glass ionomer.83 For permanen t teeth,
resinmodified glass ionomer materials are ideal from the lingual
approach, but RBCs replicate enamel appearance more ideally.
Class V restorations. Class V caries lesions in infants,
toddlers, and preschoolers are common in the primary denti-
tion. Nursing bottle and sippy cup use and early childhood
caries from all causes characteristically result in cervical decal-
cification and caries.84 The selfadhesive properties, easy hand -
ling, and acceptable toothcolored appearance of glass ionomers
greatly simplify Class V tooth repair for the youngest patients.8'"’
Likewise, permanent teeth with Class V caries lesions are
also ideally treated with RMGI cement. Children and teens
who overindulge in soda pop and high acid fruit drinks often
develop Class V caries and erosion lesions, and the fluoride
containing glass ionomers are therapeutic in that regard, because
they provide longterm reliable results.88,85
Buildup after pulp treatment
After pulpotomy or pulpectomy in primary teeth, in lieu of full
coronal coverage, glass ionomers are useful in a type of sandwich
procedure . The lost dentin is entirely replaced, the pulp spaceis filled with RMGI, and the surface above it is restored with
RBC.90,91 Although there is not a good longterm clinical trial
reporting on outcomes of this procedure, there is much anec-
dotal information reported by practitioners, seemingly all favor-
able. It is logical that the key to success is completely sealing
off access of salivaryborne bacteria to the pulp space. This
requires complete seal of cavosurface margins, which is probably
achievable. Regardless, depending on the patients’ ages and
length of time required for retention of primary teeth, stainless
steel crowns or fullcoverage anterior crowns may not always be
necessary.
ART techniqueThe ART technique (atraumatic restorative treatment) has been
introduced using traditional glass ionomer materials. In this
technique, the dentist (or other operator) uses hand instruments,
such as spoon excavators, to remove tooth structure affected by
caries. The traditional glass ionomer is then hand mixed and
placed into the cavity preparation, with the glass ionomer acid/
base reaction setting the material. The technique was introduced
first in Thailand and is now used in many Third World areas,
allowing large numbers of children affected by caries but lacking
resources—sometimes even without electricity and waterto
have their teeth treated in trad itional ways.92 Specifically for-
mulated glass ionomers have been developed for the ART
technique. These are high powder/liquid ratio traditional glass
ionomer materials, with enhanced physical properties developed
by man ipulat ion of glass particle size and dis tribution and
content of the polyacid component. In addition, several highly
refined and finely sharpened hand instruments have been
developed to allow rapid excavation of damaged tooth structure,
simultaneously preparing the cavity for some mechanical inter-
locking retention of the cement.93,94
Results of many different longterm clinical trials have
examined the effectiveness o f ART fill ings.95,100 Most o f these
studies have reported on retention of the restoration as the primary outcome measure of the treatment. Some have looked
at new caries lesions beside the surface of the restoration; none
has developed a protocol comparing the ART technique to a
control, such as a traditional inchair technique. In spite of this,
many have touted the attributes of the ART technique because
of good outcomes measured in terms of restoration retention
and the ability to treat large numbers of children in inaccessible
and isolated areas, sometimes by practitioners who might not
be able to perform standard procedures.101
The ART technique will likely be further tested and ex-
panded, and some are looking into ways o f treating dental caries
lesions medicinally, prior to restoring the teeth with the glass
ionomer material.
Summary
Glass ionomers have been a mainstay of restorative dentistry for
children for several decades. Their many formulations, clinical
uses, and unique advantages have made these materials an essen-
tial part of everyday practice for dentists who treat children.
The fluoridereleasing properties of glass ionomers will
become even more important as caries diagnostic devices, now
available for clinical use, become more sophisticated and pro-
vide better sensitivity (on proximal axial surfaces) and speci-
ficity.102,103 Awareness abou t the value of fluor idereleas ing
materials will certainly be enhanced when the localized effects
of their use can be more precisely measured.
Udpate since 2002 consensus position paper—as presented
in November 2014
Glass ionomer cement systems for use in pediatric dentistry
were extensively reviewed in 2002 as part of the AAPD Pediatric
Restorative Dentistry Consensus Confe ren ce.104,106 Since the
1970s, glass ionomer cements have proven to be the best direct
application dentin replacement materials available. RMGIs have
overcome most of the major disadvantages of the original chemi-
cally hardened glass ionomers. These materials harden initially
by photopolymerization, and the setting process continues by
completion of the acid/base neutralization reaction as the poly-
acid component reacts with the glass particles. Inclusion of the
light sensitive resin not only provides for on command harden-ing, but also makes for a filling material (or luting cement)
with enhanced physical properties compared to traditional glass
ionomers. RMGI cements are clinically practical materials with
all the advantages of glass ionomer systems as well as the bene-
fits of better handling and physical strength (wear resistance,
fracture resistance, fracture toughness, etc.) and greater durability
over time.
A continuum of adhesive tooth restorative materials was
described by Burgess et al.105 and B erg.106 This co ntin uu m
focuses on advantages and disadvantages of the RMGIs and
RBCs. For years, dental manufacturers’ research and development
teams have been working to create a dental restorative material
that has all the advantages of hydrophilic RMGIs and hydro
phob ic RBCs witho ut any disadvantages. Croll and Berg107
noted that such a material would:
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1. Chemically bond to enamel and dentin.
2. Be thera peu tic by releasing fluoride ions that are
incorporated into adjacent dentin and enamel, ren-
dering that tooth structure less soluble to acid
challenge.
3. Have an antimicrobial effect by virtue of its fluoride
content.
4. Have equivalent coefficient of thermal expansion tothat of tooth structure so that the mass of material had
sufficient dimensional stability, minimizing marginal
breakdown.
5. Not shrink or expand during the hardening reaction.
6. Be insoluble in oral fluids and acid foodstuffs (erosion
resistance).
7. Have high resistance to wear from impa ct forces,
stresses from occlusion and mastication, and wear and
tear from toothbrushing.
8. Have high cohesive streng th and resistance to both
initial fracturing and propogation of fractures.
9. Be tooth colored, highly polishable, and have easy
handling characteristics, including on commandhardening (photopolymerization).
Much effort has been expended in developing bonding
agents and appropriate methods of directly bonding RBC to
acidetched dentin, not just enamel. To this date, a resindentin
bond that does not hydrolyze over time has not been perfected.
One school of thought is that RMGf material and RBC should
be stratified to achieve the best biomimetic restorative result.108'110
This approach takes advantage of all the positive properties of
both materials, significantly decreases marginal leakage, virtually
eliminates postoperative tooth sensitivity, capitalizes on the
fluoride component of the glass particles, and helps to overcome
the effects of resin polymerizaton shrinkage.110 There has been
much academic debate offered on the subject, but we have not
encountered any cogent rationale refuting the value of adhe-
sively bonded tooth repair involving stratification of an RBC
over an RMGI liner/base.
In 2007, a new advance was achieved on the continuum
when a nanoionomer was introduced. Ketac Nano (3M ESPE,
St. Paul, Minn., USA) is a twopaste RMGI system described
by the manufacturer in its technical product profile as such:
“Paste A is resin based and contains fluoroalumino
silicate glass, silane treated silica and zirconia silica
nanofillers, methacrylate and dimethacrylate resins,
and photoinitiators. Paste B is water based and contains
polyalkenoic acid copolymer (Vitrebond Copolymer),
silane treated zirconia silica nanoclusters, silanetreated silica nanofiller, and hyroxyethylmethacrylate
(HEMA). Ketac Nano Primer contains water, HEM A,
polyalkenoic acid copolymer, and photoinitiators.”
Killian and Croll reported on the clinical use of the nano
ionomer and their experiences with the material over three
years.111 The ir unpub lished eightyear observations regardingKetac Nano are as follows:
1. RMGIs, such as Fuji II LC (GC America, Inc., Alsip,
111., USA) and Vitremer Core Buildup/Restorative (3M
ESPE), perform very well over many years, with only
two disadvantages: they have less wear resistance and
lower fracture strengths than RBCs. Experiences withKetac Nano from 2007 to 2014 show improvement in
these properties.
2. It is essential to use syringe injection of the nanoiono-
mer to avoid air incorporation into the restoration.
The orange thin lumen AccuDose Low Viscosity tips
(Centrix, Inc., Shelton, Conn., USA) work especially
well for that purpose.
3. Once the two pastes of the material are blended and
placed into the syringe tip, a delay of approximately
30 seconds before injecting is useful to make time foran initial congealing of the cement. That makes for
easier placement of the material.
4. Finishing and polishing can be achieved in the same
manner as one completes an RBC restoration. Polished
nanoionomer surfaces are smooth and lustrous, like RBC
surfaces, due to the nanofillers and nanofilled clusters.
5. In some mouths , the material yellows slightly over
the years.
6. For Class I and II repairs of primary molars, the nano
ionomer appears to be very reliable for five to eight
years until the treated tooth is lost to exfoliation. Some
isthmus fractures have occurred in Class II restorations
with larger buccolingual widths. Blunting opposing jackhammerlike cusp tips is helpful to avoid harsh
concentrated forces on the cement and enamel surfaces.
7. The resin chemistry of the nanoionomer only provides
for photopolymerization. There is no chemical resin
cure; hence, throughandthrough light beam penetra-
tion is critical for optimum hardening of the cement.
8. In regions of masticatory impact and occlusal contact,
the nanoionomer does not wear as well as an RBC.
However, significant wear, perhaps in combination
with erosion from oral fluids over time, rarely occurs
within five years to the extent that renewed treatment
is needed.
9. The nano iono mer is very useful for interim repair
of certain permanent posterior teeth (e.g., those with
enamel hypoplasia or enamel hypocalcification, with
or without associated dental caries).112
Clinical experiences echo research findings about the nano
ionomer. Studies have verified that nanofilled adhesive mate-
rials in general, and Ketac Nano in particular, resist biodegrada-
tion and abrasive wear better than conventional materials.113,114
It has also been verified that adhesion of the nanoionomer to
dentin and enamel is the same as other glass ionomer systems,
and there are two hardening mechanisms, as for other RM GIs.115
In addition, fluoride ion kinetics of the nanoionomer have
been tested, and “it was concluded that the new RM GI KN
exhibits fluoride ion release behavior similar to typical conven-tional glass ionomers and RMGIs and that the primer does not
impede the release of fluoride.”116
In the past few years, there has been an extraordinary
amount of emphasis placed on bioactive dental restorative ma-
terials.117'120 Many products are coming to market touting their
ability to remineralize dentin and enamel and rejuvenate tooth
structure in biomimetic fashion so that not only is there a repair
process at work bu t also a preventive aspect to the restorative
results. In February 2014, two new products were introduced
that show exceptional prop erties in m anufa cturer’s testing.
ACTIVA BioACTIVERestorative and ACTIVA BioACTIVE
Base/Liner (Pulpdent Corporation, Watertown, Mass., USA)
were introduced in February 2014. The company’s produ ctdescription states that “ACTIVA products are the first bioactive
dental materials with an ionic resin matrix, a shockabsorbing
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resin component, and bioactive fillers that mimic the physical
and chemical properties of natural teeth. They are durable, wear
and fracture resistant, chemically bond to teeth, seal against
bacterial microleakage, and release and recharge with calcium,
phosphate and more fluoride ions than glass ionomers.” “ACTIVA
contains no Bisphenol A, no Bis-GMA and no BPA derivatives.”
(Pulpdent publication XF-VWP REV: 05/2014).
For the restorative material, the following physical pro perties are defined by the manufacturer:
1. Light cure setting time: 20 seconds.
2. Depth o f light cure: four mm.
3. Self-cure setting time at 37 degrees Celsius: two minutes.
4. Percent filler by weight: 56 percent.
5. Percent of reactive glass by weight: 21.8 percent.
6. Fluoride release (one day): 230 ppm.
7. Fluoride release (28 days; cumulative): 940 ppm.
8. Flexural strength: 102 MPa/14,790 psi.
9. Flexural modulus: 4.3 GPA.
10. Compressive strength: 280 MPa/40,6000 psi.
11. Diametrile tensile strength: 42 MPa/6,090 psi.
12. Water sorption (one week): 1.65 percent.13. Polymerization shrinkage: 1.7 percent.
The base/liner is filled 45 percent by weight; therefore, it
does not have quite the physical strengths of the restorative
material. Both materials have excellent flowability and are easily
spread into a cavity preparation with full assurance that all
regions are covered and the preparation is saturated.
The manufacturer provides a pistol grip mixer/dispensing
system with a number of injection tips for placement of the
ACTIVA pastes. Another option of delivery into cavity prepara
tions is expression of the two pastes onto a mixing pad, spatula-
tion in the usual manner, and use of syringe delivery with
Centrix AccuDose tips, just as with the nano-ionomer. The
manufacturers disperser/mixer eliminates incorporation of air
bubbles into the blended paste; however, with care, an ideal
mixture can be achieved by hand blending with a spatula.
Pulpdent was granted 510(K) approval by the Food and
Drug Ad ministration in March o f 2013 for ACTIVA to be
marketed as an RMGI dental filling material. However, since
March 2014, one of the authors (TPC) has placed more than
300 primary tooth restorations and more than 300 permanent
tooth restorations using ACTIVA BioACTIVE Restorative.
The material handles, finishes, and polishes like RBCs. After
12 months in the mouth, these restorations are indistinguish
able from RBCs. The clinician may wonder if ACTIVA Bio-
ACTIVE-Restorative is a RBC with RMGI properties or a
RMGI that has resin-based composite physical strengths. Bothdesignations could be correct, but dentists need verification ofthat possibility.
Results of some studies about these unusual new materi
als are currently in press in dentistry journals, and some have
already been pu bl ish ed .121,122 However, more independent
laboratory and clinical studies are needed to fully determine all
properties and long-term clinical performance of the ACTIVA
materials regarding biocompatibility, polymerization shrinkage,
fracture strengths, wear resistance, solubility in oral fluids, mois
ture absorption, fluoride release and take-up, antimicrobial
properties, microleakage, and color stability.
Currently, we believe that the ACTIVA products could be
the latest major advancement on the adhesive dental restorative
mater ials cont in uu m105,106 but acknowledge tha t much more
needs to be learned about these innovative new products.123
Recommendations
The dental literature supports the use of glass ionomer and
resin modified glass ionomer cement systems in the followingsituations:
1. Luting cement:
a. stainless steel crowns;
b. orthodontic bands; and
c. orthodontic brackets (limited).2. Cavity base/liner.
3. Class I restorations in primary teeth and, in certain
cases, permanent teeth.
4. Class II restorations in primary teeth.
5. Class III restorations in primary teeth.
6. Class III restorations in permanent teeth in high-risk
patients or teeth that cannot be isolated.
7. Class V restorations in primary teeth.
8. Class V restorations in permanent teeth in high caries-
risk patients or teeth that cannot be isolated ideally.
9. Caries control:a. high caries-risk patients;
b. restoration repair; and c. ART (atraumatic restorative treatment) and interim
therapeutic restorations.
Acknowledgmen ts
The authors wish to thank John W. Nicholson, PhD, who at the
time of the original writing was a professor of Biomaterials
Ch emistry, De partm ent of Chemical, Environ mental and
Pharmaceutical Sciences, School of Science University of Green
wich, Medway Campus, Chatham, Kent, United Kingdom for
his original and erudite contributions to the 2002 glass ionomer
position paper and the science of glass polyalkenoates.
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