Cementos de Ionómero de Vidrio. Una Actualización. (ING) AAPDJournal

8/19/2019 Cementos de Ionómero de Vidrio. Una Actualización. (ING) AAPDJournal

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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 [email protected]

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.

1 16 G L A S S I O N O M E R R E S TO R A T I VE C E M E N T S Y S T E M S

mailto:[email protected]:[email protected]


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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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t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t , d o w n l o a d , o r

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