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Glass ionomer restoration

Definition:

 Glass ionomer cement has been described as a hybrid of dental silicate cement
"powder" and zinc polycarboxylate cement "liquid".

Types:

1. Conventional GIC:
A. GIC Powder:
 The powder is an acid-soluble calcium-fluoro-alumino-silicate glass similar to
that of silicate but with a higher alumina-silicate ratio that increases its
reactivity with liquid.
 The fluoride portion acts as a “ceramic flux” to reduce the melting
temperature of GI.
 Strontium, barium or zinc oxide additives provide radiopacity.
B. GIC Liquid:
 The liquid is an aqueous "watery" solution of polymers and copolymers of
polyacrylic acid*.
 Tricarboxylic acids were added to the liquid to decrease the viscosity of liquid,
and to promote reactivity between the glass and the liquid.
 Tartaric acid is also present in the liquid. It improves handling characteristics
and increases the working time, however, it shortens the setting time.
2. High Viscosity Conventional GICs
 They are useful for atraumatic restorative treatment "ART" technique as they were
developed to act as a substitute to amalgam for posterior restorations in rural
areas.
 In these cements, polyacrylic acid is made to finer grain size so that higher powder-
liquid ratios can be used "More viscosity".
 Advantages of Highly Viscous Glass Ionomers:
 Fast setting "Ch. Bond"
 Low early moisture sensitivity
 Low solubility in oral fluids "Low risk of moisture contamination".
 Finishing can be done in five minutes after placement
 Anti-cariogenic effect.

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3. Reinforced GICs: Strength of the GIC can be improved by modifying the chemical
composition of the original glass powder. It can be done by following:

A. Disperse-phase Glasses: glass was prepared with large amount dispersed phases
of strengthening.
B. Fiber-reinforced Glasses: alumina fibers, glass fiber, silica fiber and carbon fiber
were added. However, these materials showed difficulty to mix, and show low
resistance to abrasion.
C. Metal Reinforced GIC: metal powder or fibers were added to GIC to increase the
flexural strength.

The most famous type is the “Miracle mix”, which formed by incorporating the amalgam
alloy powders to the GIC. These cements show poor esthetics and resistant to burnishing
and poor resistance to abrasion.

D. Cermet Cements: GIC produced by sintering the metal and glass powders
together. It showed strong bonding of the metal to the glass. These cements have
shown improved resistance to abrasion and higher flexural strength.

4. Resin-Modified GIC
 The typical RMGIC consists of approximately 80% GIC components
(fluoroaluminosilicate glass and polyacrylic acid), while the remaining 20% consists
of light cured methacrylates to overcome the drawbacks of conventional GICs..
 Resin based bonding to tooth structure is via micromechanical mechanism and
chemically by the formation of ionic bonds between carboxyl groups of the RMGIC
and calcium ions of enamel and dentin.
 Advantages of RMGIC: combined advantages of both composites and glass
ionomers.
 Chemical adhesion to enamel and dentin with Fluoride release "Cariogenic
effect".
 Superior strength characteristics.
 Extended working time with control on setting.
 Low interfacial shrinkage stress.
 Good adaptation.
 Improved aesthetics.
 Disadvantages of Resin Modified Composites:
 Shrinkage on setting.
 Limited depth of cure especially with more opaque lining cements.

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Glass lonomer Cements mixing:

 For simple and easier manipulation of GICs, modifications have been made for
dispensing glass ionomer cement:.
A. Capsules:
 These capsules contain premeasured powder and liquid to assure correct ratio
for the mix.
 These capsules have angled nozzle which acts as a syringe for accurate
placement of the cement into a preparation.
B. Paste dispensing system:
 In this system, an ultra-fine glass powder is used to provide the cement in a
paste consistency.
 It uses a cartridge and a material dispenser.
 Advantages of this system are optimum ratio, simple placement, and easy mixing.

Setting Reaction of GIC:

 It is an acid-base reaction between the acidic polyelectrolyte and the aluminosilicate

glass. It occurs in three different but overlapping stages "phases":
A. Ion Leaching Phase:
 When the powder and aqueous acidic solution are mixed, the polyacid attacks the glass
particles (called leaching) to release cations like Ca, Al and F ions and UNREACTED IONS.
B. Hydrogel Phase "Gelation"
 In this phase, calcium ions are released rapidly, react with the acid and cross-link with
the polyacrylic acid "i.e. calcium bridges" to form a calcium polycarboxylate gel in
which the non-reacted glass is embedded.
 Water plays a Critical role in the setting of GIC. It serves as the reaction medium initially
and then cross-linked agents thereby yielding stable gel structure, which is stronger
and less susceptible to moisture contamination. So any contamination by water at that
occurs at this stage can cause dissolution of the matrix forming cations and anions to
the surrounding areas.
C. Polysalt Gel Phase
 This phase occurs when the mix reaches its final set and is continued for many months.
 In this stage continued attack of hydrogen ions cause a delayed release of Al ions from
silicate glass in the form of AIF ions which are deposited in the already preformed
matrix to form a water-insoluble Ca-Al-Carboxylate gel.
 It is the Al ions which provide strength to the cement.

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Classification of GICs

A. Traditional classification (Based on application)

 Type I - Luting cements
 Type II - Restorative esthetic or reinforced cements
 Type III - Liner or Base for pulp protection
B. Classification of GICs according to the clinical use:
 Type l - For luting cements  Type IV - Fissure sealants
 Type II - For restorations  Type V - Orthodontic cements
 Type III - Liners and bases  Type Vl - Core build up

Indications of GICs

1. Restoration of permanent teeth

 Class V, class III, small class I tooth preparations
 Abrasion/Erosion
 Root caries
2. Restoration of deciduous teeth
• Class I - Class VI tooth preparations
• Rampant and nursing bottle caries
3. Luting or cementing
• Metal restorations (Inlay, onlay, crowns)
• Nonmetal restorations (composite inlays and onlays)
• Veneers
• Pins and posts
• Orthodontic bonds and brackets
4. Preventive restorations
• Tunnel preparation
• Pit and fissure sealants
5. Protective liner under composite and amalgam
6. Bonding agent
7. Dentin substitute
8. Core build up
9. Splinting
10. Other restorative technique: Atraumatic restorative treatment.

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Advantages of GIC

 Chemical bonding to enamel and dentin through ion exchange.

 Biocompatible because large sized polyacrylic acid molecules prevent the acid from
producing pulpal response.
 Little shrinkage and good marginal seal.
 Anticariogenic because of fluoride release. This fluoride can also be recharged from
topical fluoride applications.
 Good color matching and translucency makes it aesthetic.
 Minimal tooth preparation required hence easy to use on children.
 Less technique sensitive than composite resins.

Limitations of GIC

 Low Compressive strength compared with amalgam and resin composite

 Low wear resistance
 Water sensitivity during setting phase affects physical properties and aesthetics. So it
requires moisture control during manipulation and placement
 Opaque which makes glass ionomer cement less aesthetic than composites.

Clinical steps

A. Conditioning of the prepared surface:

 For better adhesion of GIC to tooth structure, many conditioning agents have been
used for smear layer removal "Not demineralization*".
 Polyacrylic acid is the most commonly used conditioner.
B. Restorative Procedures:
 After mixing, GIC is carried with the help of cement carrier for placement into the
prepared tooth. For optimal restoration, the useage of matrix is always advisable.
 The gross excess is removed immediately and final contouring is done.
 In case of chemically cure glass ionomer, matrix is held till the initial hardening of
cement starts but in case of light cure glass ionomers, photoactivation can be done
for accelerated setting.
C. Finishing and Polishing:
 Surface of GIC is sensitive to both moisture contamination and desiccation.
 During initial phase of cement setting, it is always preferred to delay finishing and
polishing of glass ionomer cements for at least 24 hours after the cement
placement.

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D. Surface Protection
 The newly placed restoration should always be protected, as GIC show sensitivity to
both moisture contamination and surface desiccation immediately after matrix
removal.
 It can be done with the help of resin bonding agent, petroleum jelly or varnish
“Coat”.

Special techniques

A. Tunnel GIC Restoration

 A tunnel preparation is made for removal of proximal caries by making an access
through occlusal surface while leaving the marginal ridge intact.
 Indications:
 Indicated when life expectancy of tooth is not more than 5 years like in
deciduous teeth or grade 1 mobile teeth in geriatric patients.
 Incipient proximal lesions of posterior teeth
 Low caries risk patients.
 Clinical Steps
1. Bitewing radiograph is taken to know that the access area does not involve any
pulp horn.
2. Isolate and dry the tooth to be restored with tunnel preparation.
3. Place a wedge below the carious proximal portion.
4. Penetrate the occlusal surface of tooth with a round bur. Entry of bur should be 2
mm inside the marginal ridge. Angle of bur should be 45 to the carious lesion.
5. After enamel has been penetrated, spoon excavator is used to remove the caries.
Use periodontal probe to measure the depth of lesion. Widen the preparation
using tapered fissure bur.
6. Once confirmed, the complete caries removal, place a matrix band and wedge on
the proximal surface so as to avoid overhanging restoration and injury to gingiva.
7. Use restorative material and condense it from occlusal surface, avoiding any void.
8. Remove wedge and matrix and do final finishing and polishing of the restoration.
 Disadvantages:
 Incomplete caries removal.
 Can't ensure complete GIC condensation in place "Difficult visibility"

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B. Sandwich Technique
 The term “sandwich technique” refers to a intermediate restoration using glass
ionomer to replace dentin and composite resin to replace enamel.
 Advantages:
 The open sandwich technique used for deep Class II forms where the cervical
margin lacks enamel, has shown the improved resistance to microleakage and
caries in comparison to resin bonding at dentin margins.
 Better strength, aesthetics and finish of composite resins.
 Fluoride release from GIC.
 Reduced bulk of composite resins so less polymerization shrinkage.
 Minimizes the number of increments of composite resin to be placed, so saves
time.
 Use of GIC eliminates acid etching of dentin and thus reduces post-operative
sensitivity caused by incomplete sealing of etched dentin.
 Good pulpal response because of biocompatibility of GIC.
 Disadvantages:
 Technique sensitive
 Time consuming.
 Clinical Steps:
1. Isolate the tooth to be prepared.
2. Prepare the tooth keeping the cavosurface margins involving dentin butt joint.
3. Condition the prepared tooth using polyacrylic acid for optimal adhesion of GIC.
4. Place freshly mixed fast setting GIC in the prepared tooth.
5. It is only necessary to etch a GIC with acid if the restoration has been in place for
some time and has fully matured. If the GIC is freshly placed and is immature,
bonding can be achieved simply by washing the GIC surface because water causes
wash out of GIC matrix from around the filler particles which gives microscopically
rough surface to which the composite will attach.
6. Coat the surface of prepared tooth either with an unfilled resin or a dentin
bonding agent for optimal adhesion and cure it for 20 seconds.
7. Place composite and cure following its manufacturer recommendations.
8. Finishing and polish the restoration.

Thank you class 37,

“Everybody is going to die. The thing is to die well, to be remembered”.
With my all best wishes and regards,

Dr. Yasser Osama

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