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Daranee Versluis-Tantbirojn Division of Operative Dentistry Department of Restorative Sciences

Dent 5801 Operative Dentistry I Oct 9 th , 2007. Resin-modified Glass-ionomer Materials. Daranee Versluis-Tantbirojn Division of Operative Dentistry Department of Restorative Sciences. Learning objectives. Students will be able to.

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Daranee Versluis-Tantbirojn Division of Operative Dentistry Department of Restorative Sciences

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  1. Dent 5801 Operative Dentistry I Oct 9th, 2007 Resin-modified Glass-ionomer Materials Daranee Versluis-Tantbirojn Division of Operative Dentistry Department of Restorative Sciences

  2. Learning objectives 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

  3. Recall... DENT 5351 Dental cements, Dr. Combe, Feb 2, 2007 + pendant methacrylate groups Polymerization Resin-modified glass-ionomer Acid-base reaction

  4. Siliceous hydrogel Glass core Ca2+ Ca2+ Ca2+ Ca2+ Ca2+ CO-O- CO-O- Ca2+ Al3+ Al3+ Al3+ Al3+ Al3+ PO43- F- F- F- F- F- CO-O- CO-O- Ca2+ CO-O- Tooth structure -O-CO -O-CO PO43- CO-O- CO-O- Ca2+ CO-O- CO-O- PO43- CO-O- Ca2+ CO-O- CO-O- PO43- Ca/Al polyacrylate matrix Background: Chemistry and setting reactions polyalkenoic acids + calcium fluoroalumino silicate glass + methacrylate copolymer • Conventional GIs • (Acid-based reaction) • Ca2+ = initial set (minutes) • Al3+ = final set (days, weeks, months) • Resin-modified GIs Light initiated or autocure (set w/o light) methacrylate copolymer (resin-modified GI) Drawing adapted from Albers HF 1996, Tooth-color Restoratives.

  5. True glass ionomers Conventional or ‘self-cured’ ‘light-cured’ Resin-modified acid-base reaction • Mixing • Cure in the dark

  6. (Wilson & Kent 1972) (Bowen 1963) Glassionomer cement Resin composite Polyacid-modified composite(compomer) Resin-modified GI ‘Giomer’ ‘Hybrid ionomer composite’ (Geristore) True glass ionomers

  7. Glass ionomers in restorative dentistry

  8. Glass ionomers in restorative dentistry * * Fuji II LC Fuji IX Ketac Molar Ketac Fil Restorative (Filling) Vitrebond Lining * * Vitrebond Plus Ketac Bond Fuji Lining RelyX Luting RelyX Luting Plus Luting * FujiPlus FujiCem * * presently used in Operative preclinic & clinic

  9. Ion exchange layer • Adhesion to tooth structures Glass core Ca2+ Ca2+ Ca2+ Ca2+ Ca2+ CO-O- CO-O- Ca2+ Al3+ Al3+ Al3+ Al3+ Al3+ PO43- F- F- F- F- F- CO-O- CO-O- Ca2+ CO-O- Tooth structure -O-CO -O-CO PO43- CO-O- CO-O- Ca2+ CO-O- CO-O- PO43- CO-O- Ca2+ CO-O- CO-O- PO43- Advantages of glass ionomers • Release ions (F-) affect balance betweende/remin • ‘Non-irritant’ • Translucent • Better mechanical properties Compare with other cements

  10. 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

  11. 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 J Dent 2007;35:156-62 Esthetic compromise • Opaque • Surface finish

  12. 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

  13. Plaque or acid medium Z250 Vitrebond Plus/Z250 Adapted from Hicks • Anticaries property is questioned? In vitro anticariogenic potential of GIs is known How is it under clinical conditions?

  14. 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?

  15. 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

  16. 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.

  17. 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 + adhesive ~ 15-25 ~ 25 (etched porcelain & ceramic primer) * Shear mode; 3M and GC products; 3M Product Profiles

  18. 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

  19. 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 betweenGICs (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

  20. 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). Indications

  21. 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 at a waxy stage (after 2 minutes from placement) Mix with spatula for 20 second Working time 2.5 minutes

  22. % Retention Composite RMGI References 3 years 2 years 2 years 86 81 70 55 96 100 Folwaczny et al., 2001 Brackett et al., 2003 Onal and Pamir, 2005 Should I use GI restorative or composite? Clinical studies showed mixed results in Cl V retention 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

  23. Post-operative sensitivity Painful on pressure Composite leakage & Post-op sensitivity Anecdote: No sensitivity after replacing composite with glass ionomer restoration

  24. 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

  25. 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.

  26. 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?

  27. 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.

  28. How deep is deep? ~ 1 mm below DEJ* 1-2 mm from pulp* >1 mm from DEJ* 0.5-1 mm from pulp* (‘pinkish’) GI liner optional Etch & Adhesive Composite GI liner Etch & Adhesive Composite Dycal GI liner Etch & Adhesive Composite * The numbers are arbitrary for illustration purposes. It depends on the tooth, location, pulp recession, etc.

  29. Example of resin-modified glass-ionomer liner (3M Vitrebond Plus) Use clean Dycal carrier Followed by etching, bonding, filling

  30. Questions?

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