Ajman University of Science and Technology Faculty of Dentistry

Clinical Operative I Course Code 0802415

First Semester
2011-2012

GLASS IONOMER CEMENT

Lecture 3 and 4

Professor Abdul-Haq A. Suliman

GLASS IONOMER CEMENT

Historical Development and Setting reaction General properties of glass ionomer Advantages Fluoride release Adhesion Marginal adaptation and leakage Biocompatibility Esthetics Disadvantages Physical properties Water sensitivity Clinical considerations Types of glass ionomer according to formulations Conventional type Anhydrous type Metal reinforced Resin modified glass ionomer Poly acid modifies composite resin Types of glass ionomer according to use Type I luting cement Type II restorative Type III lining or base materials Dispensing and mixing Capsules Hand mixing Uses of glass ionomer In Medicine In Dentistry

Historical Development Glass ionomer was developed in the late 1960s; these materials are consisting of ion-cross-linked polymer matrices material surrounding glassreinforcing ceramics. Earlier generation were based on solution of polyacrylic acid liquid that was mixed with a complex alumino-silicate powder containing calcium and fluoride. Glass ionomer materials are considered a hybrid materials that use the alumino-silicate powder of silicate cement and the polyacrylic acid used in polycarboxylate cement. It is also referred to as polyalkenoate cement.

Typical composition of glass ionomer This material is basically supplied as powder that is mixed with the

liquid. The powder contains a fluoroaluminosilicate glass which reacts with water-soluble polyalkenoic acid to form the cement. In its original form polyacrylic acid was used, but many current materials use copolymer of acrylic acid with itaconic or maleic acid. Maleic acid reduces viscosity of the liquid and inhibits gelation by hydrogen bonding. Tartaric acid is added in a small amount to produce materials with clinically acceptable working time. The powder consists mainly of calcium fluoride (34%) and silica oxide (29%), while the remaining is a lower percentage of aluminium oxide, aluminium fluoride, sodium fluoride and aluminium phosphate. Sometimes the calcium may be replaced by strontium and barium in order to make the material radio-opaque.

Setting reaction Glass ionomer material is acid-based materials, so essentially the setting reaction is an acid-base reaction. In mixing the glass powder with the polyalkenoic acid the fluoroaluminosilicate glass is attacked hydrogen ion from the polyalkenoic acid, liberating aluminium, calcium, sodium and fluoride ions. A layer of silica gel is slowly formed on the surface of unreacted powder, with the progressive loss of metallic ions, until complete decomposition of glass particles occurs. When the free calcium and aluminium ions reach saturation in the silica gel, they diffuse into the liquid and cross-link with two or three ionized carboxyl groups of the polyacid to form gel. As the cross-linking increases through the aluminium ions and the gel is sufficiently hydrated, the cross-linked polyacrylate salt begin to precipitate until the cement is hard.

General properties of glass ionomer Conventional glass ionomer cement offer several advantages over other restorative materials. Fluoride Release Fluoride is released from the glass powder at the time of mixing and lies free within the matrix. It can therefore be released without affecting the physical properties of the cement. Since it can also be taken up into the cement during topical fluoride treatment and released again, the cement may act as a fluoride reservoir over a relatively long period. As a result, it has been suggested that glass ionomer cements will be clinically cariostatic. The amount of constant fluoride release did not differ much between brands of conventional glass ionomer cements. The fluoride release of some resinmodified materials is at least the same as conventional materials but varies amongst different commercial products. Nevertheless, the critical amount of fluoride released from a restoration that is required to be effective in inhibiting caries has not yet been established. The prolonged and substantial release of fluoride ions from glass-ionomer materials is of a major clinical significance. It is likely that further release is available from glass particles themselves because they can be regarded as being porous to ions such as these. The amount of fluoride released is high soon after placement but reduces to a constant, lower level within one week with most materials. The fluoride has been shown to be incorporated into the surrounding enamel. There is evidence to indicate a continuing release for at least 8 years after placement of restoration and almost certainly longer.

Adhesion By bonding a restorative material to tooth structure, the cavity is theoretically sealed, protecting the pulp, eliminating secondary caries and preventing leakage at the margins. This also allows cavity forms to be more conservative and, to some extent, reinforces the remaining tooth by integrating restorative material with the tooth structures. Bonding between the cement and dental hard tissues is achieved through an ionic exchange at the interface. Polyalkenoate chains enter the molecular surface of dental apatite, replacing phosphate ions. Calcium ions are displaced equally with the phosphate ions so as to maintain electrical equilibrium. This leads to the development of an ion-enriched layer of cement that is firmly attached to the tooth. The shear bond strength of conventional glass ionomer cements to conditioned enamel and dentin is relatively low, varying from 3 to 7 MPa. However, this bond strength is more a measure of the tensile strength of the cement itself, since fractures are usually cohesive within the cement, leaving the enriched residue attached to the tooth. Comparisons between resinmodified glass ionomer cements and conventional materials reveal that the shear bond strength of the former is generally greater, but that they show very low bond strength to unconditioned dentin compared to conventional materials. Conditioning therefore plays a greater role in achieving effective bonding with the resin-modified glass ionomer cements. In addition, when the enamel surface is etched with phosphoric acid, the bond strength of the resin-modified materials is close to that of composite-resin bonded to etched enamel. This suggests, along with the effects of light-curing, that the bonding mechanism of resin-modified glass ionomer cements may be

different from that of conventional materials. Margin Adaptation and Leakage The coefficient of thermal expansion of conventional glass ionomer cements is close to that of dental hard tissues and has been cited as a significant reason for the good margin adaptation of glass ionomer restorations. Even though the shear bond strength of glass ionomer cements does not approach that of the latest dentin bonding agent, glass ionomer restorations placed in cervical cavities are very durable. Nevertheless, microleakage still occurs at margins. Although resin-modified glass ionomer cements show higher bond strength to dental hard tissues than conventional materials, they exhibit variable results in microleakage tests. Not all of them display significantly less leakage against enamel and dentin than their conventional counterparts. This may be partly because their coefficient of thermal expansion is higher than conventional materials, though still much less than composite-resins. Controversy also exists as to whether the slight polymerization shrinkage is significant enough to disrupt the margin seal. Biocompatibility The biocompatibility of glass ionomer cements is very important because they need to be in direct contact with enamel and dentin if any chemical adhesion is to occur. In an in vitro study, freshly mixed conventional glass ionomer cement was found to be cytotoxic, but the set cement had no effect on cell cultures. In another study, the pulpal response to glass ionomer cements in caries-free human premolars planned for extraction was examined. The result showed that although glass ionomer cement caused a greater inflammatory response than zinc-oxide eugenol

cement, the inflammation resolved spontaneously with no increase in reparative dentin formation. Therefore, lining is normally not necessary under conventional glass ionomer restorations when there is no pulpal exposure. Concern has been raised regarding the biocompatibility of resinmodified materials since they contain unsaturated groups. A cell culture study revealed poor biocompatibility of a resin-modified liner. In contrast, it has been shown that resin-modified glass ionomer cement did not impair pulp healing when placed on exposed pulps. As a result of this uncertainty, use of resin-modified materials in deep unlined cavities is probably not advisable. The response of all soft tissues to glass-ionomer restorations is favourable. It has been shown that bacterial plaque fails to thrive on the surface of the glass ionomer. The pulpal response to glass-ionomer materials is favourable. Conventional glass-ionomer exhibit good biocompatibility for three main reasons (i) they set with minimal exotherm, (ii) neutralization is generally rapid that any potential irritation because of the presence of free acid is minimal and (iii) substances released from the set cement are generally either benign or beneficial to the tissue in which the cement is placed. Recent work suggests that glass-ionomer can be used to cover and protect a mechanical or traumatic exposure of an otherwise healthy pulp, because formation of dentin bridge can occur in spite of the lowered pH. This supports the previously held concept that it is only bacteria or their toxins that cause a continuing pulp inflammation and not a restorative material in itself. However, if there is any doubt, particularly concerning the possibility of bacterial infection, a small quantity of calcium hydroxide over the actual exposure will have a predictable result.

When used as luting agents the glass-ionomer cement might exhibit the same post insertion sensitivity as zinc phosphate cement. The reasons for selecting a glass-ionomer for cementation of indirect restorations include: Thixotropic flow properties Excellent ultimate film thickness Fluoride release Low solubility Esthetics Conventional glass ionomer cements are tooth-colored and available in different shades. Although the addition of resin in the modified materials has further improved their translucency, they are still rather opaque and not as esthetic as composite-resins. In addition, surface finish is usually not as good. The color of resin-modified materials has been reported to vary with the finishing and polishing techniques used. Potential also exists for increased body discoloration and surface staining because of their hydrophilic monomers and incomplete polymerization Disadvantages Despite these biotherapeutic and clinical advantages, practical difficulties have limited their clinical use. The use of glass ionomer cements can have limitations in very specific circumstances. Glass-ionomer cements have a short working time but a long setting time, delaying finishing of the restoration.

Physical Strengths The main limitation of the glass ionomer cements is their relative lack of strength and low resistance to abrasion and wear. Conventional glass ionomer cements have low flexural strength but high modulus of elasticity, and are therefore very brittle and prone to bulk fracture. Some glass cermet cements are arguably stronger than conventional materials but their fracture resistance remains low. The resin-modified materials have been shown to have significantly higher flexural and tensile strengths and lower modulus of elasticity than the conventional materials. They are therefore more fractureresistant but their wear resistance has not been much improved. In addition, their strength properties are still much inferior to those of composite-resins, and so should not be subject to undue occlusal load unless they are well supported by surrounding tooth structure. One of the major limitations of glass-ionomer is their susceptibility to brittle fracture. Compared to hybrid composite and dental amalgam, glassionomer materials are weak and lack rigidity. Clinical use should avoid situations that subject the restoration to heavy occlusal load or bending Water Sensitivity Conventional glass ionomer restorations are difficult to manipulate as they are sensitive to moisture imbibition during the early setting reaction and to desiccation as the materials begin to harden. Early moisture contamination disrupts its surface and removes metallic ions, while desiccation causes shrinkage and crazing. Although it was believed that the occurrence of the resin polymerization in the modified materials reduces the early sensitivity to moisture, studies have shown that the properties of the materials changed

markedly with exposure to moisture. Whether it is necessary to place protective covering on resin-modified glass ionomer restorations remains controversial. Clinical considerations Adhesion to tooth structures: adhesion of conventional glass-ionomer to enamel and/or dentin produces shear bond strengths in the range of 6 to 12 MPa. By comparison, dentin bonding agents now can produce bond strengths of 22 to 35 MPa. Most of the glass-ionomer is aqueous systems and wet tooth structure very well because they are hydrophilic. However, glass-ionomer tends to have high viscosities and therefore do not flow and adapt to micromechanical spaces very readily. In contrast, bonding agent are hydrophobic, but have been formulated for use with hydrophilic primers to facilitate wetting, flow and bonding. Bonding of glass ionomer is achieved in part by mechanical retention and in part by chemical chelation. The mechanism of adhesion of glass-ionomer to mineralized tooth structure is probably, based upon both diffusion and adsorption phenomena. Adhesion is initiated by the polyalkenoic acid when freshly mixed material contact the tooth surface. Phosphate ions are displaced from apatite by carboxyl groups, each phosphate ion will take a calcium ion with it to retain electrical neutrality. The setting of the material and dissolution of the enamel or dentin surface result in buffering of the polyacid, a rise in the local pH and reprecipitation of minerals at the cement-tooth interface. Therefore, it appears that chemical bonding is achieved by a calcium phosphatepolyalkenoate crystalline structure acting as interface between enamel or dentin and the set material. This can be described as diffusion-based adhesion. Adhesion to the organic component of the dentin may also occur

through either hydrogen bonding or metallic ion bridging between carboxyl groups on the polyacid and the collagen molecules of the dentin. Logically, adhesion will take place best in a clean environment. Various agents have been proposed to remove some or all of the smear layer and possibly preactivate the enamel and dentin. Low molecular weight acids such as tartaric acid or hydrogen peroxide were recommended initially, but the most desirable have proved to be a low-concentration polyacrylic acid applied for brief period and washed thoroughly from the tooth surface. Polyacrylic acid is part of the glass ionomer system; therefore, any remaining residue will not interfere with the setting reaction. Both the glass ionomer and the tooth structure have high surface energy and application of the polyacrylic acid will lower the surface energy of the tooth and thus increase the wetability of the surface and encourage the adaptation of the material to the tooth. The following routine is recommended for the placement of glassionomer material Prepare the cavity surface as smooth as possible. Clean the tooth surface, where access permits, using slurry of plain pumice and water. Apply a liberal coat of 10% polyacrylic acid for 10 seconds. Wash vigorously with air-water spray for 10 seconds. Dry lightly but do not dehydrate the surface.

The glass-ionomer is now immediately syringed into place and supported positively with a matrix to assist adaptation between the glassionomer and the dentin and enamel.

10

Types of glass ionomer according to formulations In general, glass ionomer cements are classified into three main categories: conventional, metal-reinforced and resin-modified 1. Conventional type: Conventional glass ionomer cements were first introduced in 1972 by Wilson and Kent. They are derived from aqueous polyalkenoic acid such as polyacrylic acid and a glass component that is usually a fluoroaluminosilicate. When the powder and liquid are mixed together, an acid-base reaction occurs. As the metallic polyalkenoate salt begins to precipitate, gelation begins and proceeds until the cement sets hard. 2. Anhydrous type: Recently, several faster setting, high-viscosity conventional glass ionomer cements have become available. These restorative materials were originally developed in the early 1990s for use with the atraumatic restorative treatment in some developing countries. These materials set faster and are of higher viscosity because of finer glass particles, anhydrous polyacrylic acids of high molecular weight and a high powder-to-liquid mixing ratio with improved strength. The setting reaction is the same as the acid-base reaction typical of conventional glass ionomer cements. In this form the acid has been freeze dried and includes in the powder, the liquid then being either water or a dilute aqueous solution of tartaric acid. With lower powder-to-liquid ratio and relatively low viscosity, this cement will be suitable for luting or lining purposes. 3. Metal reinforced glass ionomer cement: Metal-reinforced glass ionomer cements were first introduced in 1977. The addition of silver-amalgam alloy powder to conventional materials increased
11

the physical strength of the cement and provided radiopacity. Two type of modification have been employed. The first approach is that mixing spherical amalgam alloy powder with type II glass ionomer powder. This cement is referred to as silver alloy admix or miracle mix. In the second system the silver particles were sintered onto the glass with high temperature sintering, and a number of products then appeared where the amalgam alloy content had been fixed at a level claimed to produce optimum mechanical properties for glass cermet cement. To which titanium oxide may be then added to the powder to restore the material to be clinically acceptable color. 4. Resin modified glass ionomer: In 1992, resin-modified glass ionomer cements were developed that could be light cured. In these materials, the fundamental acid-base reaction is supplemented by a second resin polymerization usually initiated by a light-curing process. In their simplest form, they are glass ionomer cements that contain a small quantity of a water-soluble, polymerizable resin component. More complex materials have been developed by modifying the polyalkenoic acid with side chains that could polymerize by light-curing mechanisms in the presence of photo initiators, but they remain glass ionomer cements by their ability to set by means of the acid-base reaction. The resin modified glass ionomer materials are hybrid materials of traditional glass ionomer cement with small addition of light curing resin , and hence it exhibit properties intermediate to the two, with some characteristics superior to the conventional glass ionomer cement. Generally, they have the advantages of adhesion
12

to tooth structure, aesthetics, fluoride release and rapid hardening by light curing. 5. Polyacid modified composite resin (compomer): the compomer was introduced as a type of glass ionomer, with the claims that it offered some fluoride release as well as improved physical properties and clinical characteristics. But from its clinical use and performance it is best considered as a type of composite resin. The compomers presently available contain resin and fillers common to composite resins and glass ionomer. The resin component contains functional groups of polycarboxylate acid and methacrylates combined in one molecule. This provides methacrylic groups for cross-linking (as in composite resins) and carboxyl groups to undergo acid-base reaction in the presence of water and metal ions (as in glass-ionomer). These materials will not set without light activation because their content is insufficient to promote acid-base reaction in the dark. This is a critical difference which distinguishes polyacid modified compomers from glass ionomer.

Types of glass ionomer according to use

Type I luting cement: Use for cementation of crowns, bridges, inlays and orthodontic appliances. They are fast setting with powder/liquid ratio of 1.5:1.0. The following are the main reasons for regarding glass-ionomer as useful for luting indirect restorations. Fine ultimate film thickness, easily obtained because of good flow properties. Low solubility in oral environment.
13

 Tensile strength and abrasion resistance equivalent to zinc phosphate. Presence of continuing fluoride release. High tissue tolerance of both pulp and gingival tissue.

Type II restorative Type II.1 restorative aesthetic: use as aesthetic restorative materials which is either auto cure with slow resistance of water uptake and loss, or as resin modified with immediate resistance to water uptake. The powder liquid ratio is 3:1 or greater. The following are the main reasons for the use of these materials as aesthetic restoratives: Adequate aesthetic and translucency are available in both the auto cure and the resin modified materials. Physical properties are sufficient so long as the restoration is fully supported by surrounding tooth structure and it is not subjected to undue occlusal load. Adhesion can be achieved with the underlying tooth structure through the ion-exchange mechanism, thus completely eliminating microleakage. Conditioning with 10% polyacrylic acid for 10 seconds is sufficient to remove smear layer following cavity preparation to achieve the ion exchange. The material act as a fluoride reservoir. The continuing release of fluoride inhibits plaque formation on the restoration, thereby enhancing tissue tolerance as well as providing a source of fluoride for remineralization of any adjacent demineralised tooth structure.

14

Type II.2 Restorative reinforced: use in situations where a fast setting material is desired with increased physical properties, but where the color match of the restoration with tooth is not important. The powder liquid ratio is 3:1 or greater.

Type III Lining or base materials: there are two different applications for this group depending on the powder: liquid ratio used. Lining which is used in thin section as thermal barrier under metal restorations, to prevent thermal changes irritating the pulp and to seal dentinal tubules, preventing dentinal fluid flow into any space under restoration. The powder liquid ratio is 1.5:1. Lining cements have relatively low physical properties and are designed to be entirely covered by another restorative material. They should be used in thin section to fill voids in the cavity design and act as a thermal insulator to prevent pulp insult. Because of their physical properties, they should not be expected to act as a bonding agent for the overlying restorative material. Under no circumstances should they be left exposed to the oral environment. High powder: liquid content (ratio 3.0:1.0 or greater). Used as a base or dentin substitute. When the cement is mixed with high powder content, it can be regarded as a dentin substitute and a significant part of a total restoration. Always use the strongest restorative materials with highest possible powder content and completely restore the cavity with glassionomer. It can then be cut back to make room for stronger material, such as amalgam or composite resin, to be laminated over it. This will improve both the ultimate physical properties and the adhesion to dentin of the combined restoration.

15

Dispensing and mixing Glass-ionomers are available commercially in two forms. Encapsulated, for mechanical mixing. Powder and liquid supplied separately, for hand mixing

Capsules There are several types of capsules available and use of such system provides a consistent and satisfactory powder/liquid ratio. This result in standardised mixing and setting times, and ensures optimum physical properties. A further advantage lays in the fact that capsule also act as a syringe for placement of the mixed material into the cavity. Quality control in the manufacture of the capsule very high, but care must be taken in activating a capsule to ensure the full release of the liquid into the chamber containing the powder. Also pay attention to the manufacturers directions on machine mixing. The time of mixing will vary from one manufacturer to another and there may be variations in the consistency of the energy provision of different mixing machines. Hand mixing Hand mixing of all types of cements is possible, although great care is required when dispensing the powder to avoid under-dispensing or overdispensing. Physical properties are heavily dependent upon the powder content; for optimum result, full measure is imperative. It is also not possible to vary the size of a drop of liquid, and it is difficult to dispense accurately by half a spoon of powder; therefore, it is unwise to attempt a partial mix. The principal objective in mixing these materials is to wet the surface of each glass particles, without dissolving the powder completely in the
16

liquid. The strength of the set cement lies in the remaining glass particles rather than in the matrix. Therefore, the mix should be undertaken quickly on a cool dry glass slab without spreading the mix around or spatulating heavily. The powder should be dispensed onto the slab, then divided in half and mixed in two parts. The first part should be incorporated by gently but rapidly rolling the powder into the liquid within 10 seconds. Now, include the second part entirely, leaving no residue, and finish the mixing within a further 15 seconds. The finished mixed material should be glossy wet on the surface and the working time should now be between 60-90 seconds. For convenience, it should be transferred to a disposable syringe for accurate and positive placement into the cavity.

Uses of glass ionomer In Medicine It can be used in orthopaedic surgery as bone cement; it can also be used in otologic reconstructive surgery In dentistry Glass-ionomer can be used in many areas of restorative dentistry, among these are It can be used to restore class III and class IV lesions. Simple one surface restoration that is not under occlusal load can be restored with glass-ionomer restorative. Fissure sealants: modern high viscosity glass-ionomer cement are now preferred materials for fissure sealing, and these can placed under finger pressure to adapt the cement to the depth of the fissure. Root caries: glass-ionomer is the material of choice for root caries,
17

due to the excellent ion exchange, adhesion to dentin, caries inhibition and simplified placement control as compared to composite resin. Patient with high caries risk, for obvious reason due to fluoride ion release. In endodontic treatment as root canal sealer, and in surgical endodontic because of its minimal irritation potential to the perradicular tissues and it is known that fluoride release may contribute to bone remineralization. Also it may be used in perforation repair, and repair of root resorption. It may also be used in the treatment of vertical root fracture. Finally glassionomer performs well as a coronal restorative material. Glass-ionomer is useful in the treatment of eroded areas. Glass-ionomer can be used as a restorative material in primary teeth. Glass-ionomer can be used as a luting agent. Glass-ionomer can be used as a base or liner. Glass-ionomer can be used as a core build up materials.

18