Direct Esthetic Restorative Materials Pt.

2
1. Glass ionomer cement
2. Resin-modified glass ionomer cement
3. Compomers
4. Bonding agents

1. Glass Ionomer Cement:

➢ Used in cervical and class 5 restorations in
adults where esthetics is not critical
➢ Recommended for patients with a high risk of
carries
○ The filler has a different composition
○ It releases fluoride.

➢ Types of Glass ionomer:

Type 1: Luting (gluing) Type 2: Restorative Type 3

- Low viscosity - Higher viscosity - Used as liners and bases

- Finer glass particles - Larger particles (50um) - base cement in big
(about 15um) - P.L ratio: 3.1:1 , up to cavities
- To attach crown 3.6:1
- P/L ration 1.7:1 - Setting time: 7 minutes
(1.7 grams of powder for
1 milliliter of liquid)
- Setting
time:
4-5
mins

Indication of GIC Type II:

➢ Situations of high caries activity
○ Elderly
○ xerostomia - when there’s not enough saliva to keep the mouth wet
➢ Small non-stress bearing restorations
➢ Cervical cavities: (when the cavities are near to the gums in a way)
○ Abfraction: type of tooth wear that causes progressive loss of tooth
structure
➢ Core buildups
➢ Intermediate restorations
➢ Primary tooth fillings
Conventional Glass Ionomer (1970):
➢ Composition:
○ Powder: SiO2 , CaF2, Al2O3, AlF3, AlPO4, Na3AlF6
■ Ion leachable calcium fluoro aluminosilicate glass
○ Liquid: polyacrylic acid, itaconic acid/maleic acid, tartaric acid,
water
■ Polyacrylic Acids:
● Polymeric carboxylic acids
● COOH group
● Weak acid
Acrylic: highly reactive carboxylic acid
that can react with itself to form
polyacrylic acid.

Maleic Acid: dicarboxylic acid

Itaconic Acid: classified as a

dicarboxylic acid

Tricarboxylic acid

Tartaric Acid:
Improves handling
Extends working time
Decreases setting time - sets faster
Extends shelf life.

Setting Reaction: Acid-Base Reaction:

➢ When the powder and liquid are mixed for a GIC, the acid starts to
dissolve the glass
➢ Releases:
○ Calcium ions
○ Aluminum ions
○ Fluorine ions
➢ The polyacrylic acid chains are cross-linked by the calcium ions,
and form calcium polysalts
○ Polysalts are responsible for the initial set (calcium is
released more rapidly)
➢ Aluminum ions are released more slowly, they become involved in
setting at a later stage by forming aluminum polysalts.
 ➢ Fluorine ions do not participate in the cross-linking of the cement, they are dispersed
within the cross-linked (matrix) phase.
➢ GIC is not as esthetic as composite.
➢ The set cement consists of:
○ Undissolved particles with silica gel
coating embedded in an amorphous
matrix of hydrated calcium and
aluminum polysalts containing
fluoride.
➢ Before the stage of incorporation of aluminum
in the matrix structure, the material remain
very weak and soluble.

Role of Water in Setting of conventional GIC:

➢ Water hydrates the cross linked matrix:
○ Increases strength
○ Results in stable gel structure
➢ If the same matrix is exposed to ambient air (outdoor air)without any covering,
surface will craze and crack as a result of desiccation (extreme dryness)
➢ Any contamination by water at this stage will result in diproportionate quantities and
can cause dissolution of the matrix, forming cations and anions to the surrounding
areas.
○ Process results in weak and more soluble cement
➢ To lower the risk of dehydration and the tendency to craze the surface:
○ The surface must immediately be protected with varnish supplied with GIC or
with petrolatum
○ Final setting after 24 hours.

Mechanism of Adhesion:
➢ GIC binds to tooth structure by chelation of the carbxyl groups of the
polyacrylic acids with the calcium in the apatite of the enamel and
dentin
○ Chelation: a type of bonding of ions and their molecules to
metal ions.
Fluoride Release:
➢ Anti cariogenic property
○ tending to prevent tooth decay
➢ Rapid early release from the matrix
➢ Slow, long term release from glass particles
➢ It does not take part in matrix formation
➢ It does not result in loss of physical properties
➢ Recharge when exposed to F treatment dentifrices
 Conventional GIC (type 2)

Advantages: Disadvantages:

- Chemical adhesion to tooth structure - Sensitive to moisture and

- Coefficient of thermal expansion desiccation
(COTE) similar to tooth - Susceptible to acid attack
- Fluoride release - Low fracture strength
- Biocompatible - Low flexure strength
- Low wear resistance
- Relatively poor esthetics (high
opacity)

Manipulation of Glass Ionomer:

➢ Powder/Liquid:
○ Mixed manually on a paper pad or cool, dry, glass slab
○ Glass slab increases the working time of the cement.
➢ Premeasured Capsules (Unit-Dose Capsules):
○ Triturated (grind) and expressed through a dispenser

Mixing of the Cement:

➢ Liquid should not stay on paper pad longer than 1 minute (some of it may soak into it)
➢ Don’t mix beyond 30 seconds
➢ Divide into 2 halves:
○ First half folded into liquid in 10-15 seconds.
○ Second half incorporated in 15 seconds
➢ Small mixing area
➢ End: glossy, like condensed milk
➢ If in doubt, refer back to manufacturer instructions.

GIC restorative material type 2:

➢ Modified Versions of GIC Restorative Materials:
1. Metal-reinforced glass ionomer cements:
● Metallic fillers have been incorporated in GICs to improve fracture toughness
and stress-bearing capacity.
● Ex: cermet, useful for core buildups
2. High-Viscosity Glass Ionomer Cement:
➢ These GICs contain smaller glass particle sizes
➢ Higher P/L ratio, yielding greater compressive strength
➢ They exhibit excellent packability for better handling characteristics
➢ Used for atraumatic restorative treatment (ART)
2. Resin-Modified Glass Ionomers (Hybrid Ionomers)
➢ Restorations in low-stress bearing areas
➢ Recommended for patients with a high caries risk
➢ These restorations are more esthetically pleasing
○ Because of the resin content
➢ To overcome moisture sensitivity and low early strength due to slow acid-base
reaction:
○ Powder:
■ Similar to GIC plus initiators such as camphorquinone and/or chemical
curing
○ Liquid:
■ Monomers (methacrylate and hydroxyl ethyl methacrylate HEMA)
■ Aqueous solution of polyacrylic/polycarboxylic acid (polyacid)
■ Water
■ Tartaric acid

Setting reaction (RMGIC):

➢ Resin-modified glass ionomer cements are set by acid-base and both light cured and
self cured resin polymerization reactions
➢ Traditional glass-ionomer acid-base reaction:
○ Proceeds more slowly
➢ Free-radical polymerization:
○ Similar to composites
■ Light initiated
■ Chemical
➢ Cross linked resin-reinforced matrix.
RMGIC

Advantages: Disadvantages:

- Early strength is better than - Polymerization shrinkage

conventional GIC - Less biocompatible (HEMA)
- Less sensitive to moisture during
setting
- Set immediately and can be finished
immediately
- Esthetically better than glass
ionomers (because of resin content)
- Fluoride release and recharge

Modified versions of RMGIC Restorative Materials:

1. Tri-cure glass ionomer cement:
● In addition to photoinitiators, self-cure chemical imitators are added so that the
methacrylate polymerization can proceed in the absence of light
● The three curing reactions are:
 ○ Acid-base glass ionomer reaction
○ Light-activated polymerization
○ Chemically activated polymerization
● This allowed resin-modified glass to be used as bulk-cured materials.
2. Nano-ionomer:
➢ Nanoparticles such as nanomers and nanoclusters are added to the FAS
(fluoroaluminosilicate) glass to improve the polishability and the optical
characteristics.

Manipulation of RMGIC:
➢ Resin-modified glass ionomers are packaged in powder-liquid encapsulated or
paste-paste forms
➢ Their manipulation is like that of glass ionomers
➢ Unlike glass ionomer restorations, resin-modified glass ionomers are set immediately
when light-cured and can be finished immediately.

3. Compomers:
➢ Composite and glass ionomer
➢ Compomers:
○ Composites modified with polyacid groups
○ Matrix:
■ Dimethacrylate monomer
■ Carboxylic groups (polyacid)
○ Filler:
■ Fluoride-releasing silicate glass
○ No water

Setting Reaction Compomer:

➢ Free-radical polymerization reaction
○ Similar to resin composites
○ Filler 42-67% by volume
➢ No chemical bond to tooth structure (need to use bonding agent)
➢ Setting primarily by light-cured polymerization + delayed acid-base reactions as it
absorbs water after placement and on contact with saliva.
➢ Low levels of fluoride release
➢ Compomers are packaged as single-paste formulations in compules (gun-looking
devices) and syringes.

Properties of Compomers:
➢ Release fluoride by a mechanism similar to that of glass and resin-modified glass
ionomers
➢ Low amount of glass ionomer present in compomers = amount of fluoride release
and its duration are lower than those of glass and resin-modified glass ionomers.
 ➢ Compomers do not recharge from fluoride treatments or brushing with fluoride
dentifrices as much as glass and resin-modified glass ionomers.

Compomers in Dentistry:
➢ Direct Restorations:
○ Restorations in low stress-bearing area
○ Anterior restoration (front)
➢ Luting Cements:
○ For cementing prosthesis with metallic substrate

Light Curing Units:

➢ Visible light-curing units are used to activate the polymerization of light-cure
materials
Light Curing Units:

1. Quartz-tungsten halogen bulb (QTH):

● Wide range of light spectrum - needs filter
● Low light intensity
● The intensity of the bulb diminishes with use, so a calibration meter is
required to measure the intensity
● Generating low heat
● Curing time: 30 seconds
● Cost: less expensive.

2. Plasma arc Curing Unit (PAC)

● Wide range of light spectrum- needs filter
● High light intensity
● Generate high heat
● Curing time: 3-4 seconds
● Cost: expensive
3. Argon Laser Curing Unit
● Emitted radiation only in the blue part of the light spectrum- no filter
needed
● Highest light intensity
● Generates high heat
● Curing time: few seconds
● Cost: highly expensive

4. Light emitting diode (LED) units:

● Cordless and rechargeable
● An eye protection device (usually an orange plastic shield) may be attached
● Emit radiation only in the blue art (440-480nm)
● Lowest light intensity
● Generates low heat
● Curing time: 30 seconds
● Cost: less expensive

Principles of Bonding: Enamel and Dentin Adhesion:

Adhesive Dentistry:
➢ Branch of dentistry that deals with adhesion, or bonding with natural tooth surfaces
(enamel and dentin)
➢ “Adhesion” comes from adhering: to stick to
➢ Adherend: the surface or substrate that is adhered
➢ Adhesive/Adherent: a material that can join substances together, resist separation, and
transmit load across the bond (the glue)

Bonding and Adhesion:

➢ Comprise a complex set of physical, chemical, and mechanical mechanisms that allow
the attachment and binding of one substance to another
➢ A dental bonding system performs three main functions:
○ Provides resistance to separation of an adherend substrate (enamel, dentin,
metal, composite, ceramic) from a restorative or cementing material
○ Distributes stress along bonded interfaces
 ○ Seals the interface via adhesive bonding between dentin and/or enamel and
bonded material.
➢ This increases the resistance to microleakage and decreases the risk of postoperative
sensitivity, marginal staining, and secondary caries.

Mechanical Dental Adhesion:

➢ Mechanical adhesion: interlocking of adhesive with irregularities in the surface of
the substrate, or adherend.
○ This would involve the penetration of resin and the formation of resin tags.

Variations in Tooth Structures:

➢ Enamel: more predictable bonding
○ More homogenous structure
○ Higher inorganic (hydroxyapatite) content: 96%
○ Higher surface energy
➢ Dentin: less predictable bonding with higher organic content than enamel
(30% organic content and water)
○ Higher variability in tooth structure
➢ Dentinal Tubules radiate from pulp
○ They are largest near the pulp
■ 2.5 microns at pulp
■ 0.8 microns at DEJ
○ Concentrated near pulp:
■ 45,000/mm^2 at pulp
■ 20,000/mm^2 at DEJ

Enamel Bonding:
➢ The first meaningful demonstration of intraoral adhesion was reported by Micheal
Buonocore - in 1955
➢ Buonocore etched enamel surfaces with various acids and found a great
increase in the resin-enamel bond strength
➢ Enamel Etching:
○ The acid etching of a tooth surface allows for the micromechanical
adhesion of resin to the tooth.
○ Increase surface roughness:
 ■ when phosphoric acid is applied, hydroxyapatite goes into the solution,
leading to a predominant loss of enamel prism periphery and loss of
prism core (creating micropores of about 10 microns deep)
Raising Surface Energy:
➢ Layer of pellicle that covers the surface of enamel has low surface
energy,
○ by removing these surface contaminants, the underlying surface
enamel is exposed featuring high energy and so high reactivity.
➢ The higher surface energy ensures that:
○ resin monomers (hydrophobic) will readily wet the surface,
○ infiltrate into micropores, and
○ polymerize to form resin tags (mechanical interlocking)

Factors that Affect the Success of Acid-Etch:

➢ The three major factors which affect the success or failure of acid-etch bonding
systems are:
○ Etching time:
■ This should be sufficient to cause effective etching as evidenced by a
white, chalky appearance on the treated section of
enamel after washing and drying
■ Etching time normally is less than 60 seconds
■ Enamel: 20-30 seconds
■ Dentin: 10-20 seconds.
○ Washing stage:
■ Following etching, the enamel surface should be
washed with copious amounts of water to remove
debris
■ Washing time is usually 60 seconds
○ Drying stage:

Bonding to Dentine:
➢ Dentin etching did not gain wide acceptance until Fusayama introduced the total-etch
concept in 1979
➢ For this method:
○ Both the dentin and enamel are etched simultaneously with 37%
phosphoric acid
○ Pulp damage did not occur as has generally been assumed
➢ A subsequent study by Nakabayashi et al. 1984 revealed that:
○ Hydrophilic resins can infiltrate the surface layer of acid-demineralized
collagen fibers that are produced in etched dentin
○ It can form a layer of resin-infiltrated dentin with high cohesive strength.
Bonding Agents:
➢ Bonding agents are used with composites to provide an adequate bond to enamel and
dentin
➢ An adequate bond resists forces caused by the polymerization of the composite
and by forces of occlusion
➢ A bonding agent consists of 3 components:
○ Etchant
○ Primer
○ Adhesive

Dentin Bonding Agents:

1. Dentine conditioner (cleanser & etchant):
➢ Phosphoric acid (34% to 37%)
➢ Nitric acid
➢ Maleic acid (10%)

➢ Acids used to prepare dentine surfaces

○ Increase surface roughness:
■ It causes the hydroxyapatite to be dissolved and result in
opening the dentinal tubules to a depth of 1-5 um forming a
demineralized surface layer of dentin with increased surface
permeability.
○ Raising surface energy:
■ By removing the smear layer formed on the dentin.
■ The smear layer is a layer of microcrystalline and organic
particle debris
➢ The amount of water left in etched dentin is critical
○ If insufficient water is present, the collagen network will collapse and produce
a relatively impermeable layer that prevents resin infiltration and subsequent
hybridization
➢ Too much water remains = resin infiltration cannot fully replace the water in the
collagen network and sets the conditioner for later leakage into those locations.
➢ That’s why a priming step is required to maintain a hydrated collagen network
while removing excess water.
2. Coupling Agent (primer):
➢ Primers are solutions containing hydrophilic monomers (acetone, ethanol, or water)
○ ex: - HEMA (2-hydroxyethyl methacrylate)
○ 4-META (4-methacryloxyethyl trimellitic anhydride)
➢ Dentine is hydrophilic, whereas most adhesives are hydrophobic.
➢ Primers are bifunctional molecules:
○ one part of the primer enters into the chemical union with the
hydrophilic tooth surface to maintain an expanded collagen network
while removing water to allow for the infiltration of the hydrophobic
adhesive monomer.
○ Other part attaches to the hydrophobic resin by copolymerization

➢ The application of a bonding agent may require a drying step to evaporate the solvent.

3. Adhesive:
➢ Hydrophobic monomers with crosslinking and Co-polymerizing function.
○ Bisphenol-A-glycidyl methacrylate (Bis-GMA)
○ Urethane dimethacrylate (UDMA)
○ Triethylene glycol dimethacrylate (TEGDMA)
➢ The dentine surface is sealed with resin (adhesive) which is bonded to the
dentine via the coupling agent.
➢ The adhesive will bond to composite resin.
➢ The resulting layer of dentine and resin is referred to as Hybrid Layer.
➢ Hybrid layer: An intermediate layer of resin, collagen, and dentin is
produced by acid etching of dentin and infiltration of resin into the
conditioned dentin

Dentin Bonding Agents:

➢ Seven generation
Currently Available Generations:

Fourth Generation: Three step

Total etch - Conditioner, primer, adhesive
- In total-etch (or etch and rinse): multiple bottle systems
- Components are packaged separately.

Fifth generation: Two-step:

Total etch - Conditioner, (primer + adhesive)
- In total-etch, single-bottle systems
- Primer and adhesive are combined

Sixth Generation: Type 1:

Self etch - Two-step (acidic primer/adhesive)
2 mixed together in one bottle

Seventh generation: Type 1:

Self etch - One step, 1 bottle self etch
- Universal: one step self etch or tota etch

➢ Self-etching, sixth- and seventh-generation, and universal systems contain acidic

primers/ adhesives, which allow them to be used without prior etching with
phosphoric acid and without rinsing.
➢ Universal bonding agents may contain special primers for bonding to silica- and
zirconia-based ceramics and metals.