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Resin-Modified Glass Ionomer Cement: The Holy Grail of Cements?

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ental cements are a key link in the placement of laboratory-fabricated fixed prosthodontic restorations. The choices for these restorations include all-metal restorations (crowns and partial coverage); all-ceramic restorations either fabricated from feldspathic porcelain, pressed porcelain, and metal oxide; and porcelain-metal crowns. The clinician is also faced with choices for luting agents when placing posts and stainless steel crowns. It would be ideal if there was one cement that suited all clinical situations. This cement would be easily mixed and go through its setting reaction either quickly for a single crown or inlay/onlay or could be adjusted to set slower for multiunit, more involved cementation cases. Unfortunately, this “Holy Grail” of cements is not available. In the past (and continuing still) the term “permanent” cement has been the catch phrase when describing the use of cement for final, definitive cementation of indirectly placed laboratory-fabricated restorations. Unfortunately, “permanent”—as it relates to restorative procedures—is inaccurate and gives our patients a false sense of security and expectation. According to the leading textbook on fixed prosthodontics, the future trend when describing a cementation in restorative dentistry should focus on the placement cementation so that the restoration cannot be removed at a
Howard E. Strassler, DMD, FADM, FAGD Professor, Division of Operative Dentistry Department of Endodontics, Prosthodontics and Operative Dentistry University of Maryland Dental School Baltimore, MD Phone: 410.706.7551 E-mail: hstrassler@.umaryland.edu

later time. A more proper description of cementation should be “definitive cementation.”1 However, there are factors and properties that can be defined when choosing the best cement for a given situation. Evaluation of a true all-purpose cement has included quantifying specific physical properties and handling characteristics.1-3 The ideal properties of an all-purpose universal cement include: • low viscosity for easy restoration seating • easy to mix • long working time • short setting time • film thickness compatible with full seating of a restoration • insolubility in the oral cavity • high shear strength • high tensile strength • high compressive strength • bondable to tooth and restoration • biocompatible with pulp and soft tissue • translucent • radiopaque Improper and incorrect cement selection for the restorative material being cemented and poor technique during cementation of the restoration can lead to premature failure of these costly restorations—costly to practitioners in laboratory fees; costly to patients for the restoration, and in some cases costly to the practitioner in terms of their reputation and perceptions of the staff about the successes or lack of success with certain procedures. Although there is no one type of cement that fulfills all the criteria of a universal cement, the properties of resin-modified glass ionomer (RMGI) cements allow for use in a variety of clinical applications (Table 1).4, 5 RMGI cements are different from conventional glass ionomer ceDental Learning / April 2011 1

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Table 1

Primary Clinical Indications for Use of Resin-Modified Glass Ionomer Cements

• • • • • • •

All-metal and porcelain-metal restorations Alumina or zirconia core all-ceramic restorations Lithium disilicate pressed ceramic crowns Lithium disilicate pressed ceramic inlay/onlay CAD/CAM lithium disilicate restorations Implant-supported crowns and fixed partial dentures Metal posts (cast post and core and metal prefabricated posts)

Table 2

Partial Listing of Resin-Modified Glass Ionomer Cements Manufacturer GC America, Inc GC America, Inc 3M ESPE 3M ESPE

Product Name Fuji Plus FujiCem RelyX Luting RelyX Luting Plus

contaminants (Figure 1). The soft tissue must be healthy or, at the least, any bleeding or seepage must be controlled. Finally, during the cementation procedure, the field of operation must be clean and dry through all the steps of cementation. Research has demonstrated that resin-based cements have different physical characteristics and properties that influence the seating of crowns during cementation.6, 7 The hydraulic forces needed to completely seat a crown, inlay, and onlay using a RMGI cement or composite resin cement requires the use of a mechanical advantage. After seating the restoration, it is important that the patient apply force to the restoration to ensure full seating. This author usually has the patient bite down on a saliva ejector (Figure 2). When seated, the cement should be allowed to set for several minutes; excess should be cleared away when it reaches the gel stage (Figure 3) or after complete setting.

ments in that conventional glass ionomer cements are water based without any resin. RMGI cements have approximately 10% resin added to the formula to improve physical properties and eliminate some of the problems seen with conventional glass ionomers. Both types of glass ionomer cements are adhesive to enamel and dentin by means of ionic bonding of the glass ionomer to the calcium and phosphate ions of the tooth. It usually takes 24 hours for the final adhesive values to be attained. Besides being self-adhesive through chemical bonding to the tooth structure, glass ionomers have the additional benefit of leaching fluoride to the adjacent tooth structure, that provides some protection against recurrent caries. Both types of glass ionomer cement have low solubility. The latest generation of RMGI cements mix easier and more consistently (Table 2). They are provided as paste/paste formulations that can be mixed on a disposable paper pad or in predose capsules that are activated and mixed using a mechanical mixer. These predose capsules are then loaded into application guns and have dispensing tips so the RMGI cements can be easily applied into a crown, fixed partial denture abutments, or to the tooth preparation. The applicator guns are usually manufacturer specific.

Figure 1—Preparations for a 3-unit fixed partial denture after cleaning with pumice and a prophylaxis cup.

Cementation Technique
There are critical elements during any cementation procedure. The tooth preparation must be clean and free of

Figure 2—Three-unit porcelain-metal fixed partial denture being cemented with resin modified glass ionomer cement (FujiCem) with patient biting on a saliva ejector.

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Disclosure: Dr. Strassler is affiliated with, receives research support, and/or is a consultant for GC America and 3M ESPE.

References
1. Powers J. Cements In: Powers JM, Sakaguchi RL. Craig’s Restorative Dental Materials. 12th ed. St. Louis, MO: Mosby Elsevier; 2006:479-512. 2. Johnson GH, Lepe X, Zhang H, et al. Retention of metal-ceramic crowns with contemporary dental cements. J Am Dent Assoc. 2009;140:1125-1136. Figure 3—Removing the excess cement when it reaches a gel phase. 3. Rosensteil S, Land M, Fujimoto J. Luting agents and cementation procedures. In: Contemporary Fixed Prosthodontics. 4th ed. New York: Elsevier;2006:909-927. 4. Platt JA, Duke ES. Resin-based luting cements. Compend Contin Dent Educ. 2000;21:40-44. 5. Platt JA. Resin cements: into the 21st century. Compend Contin Dent Educ. 1999;20:1173-1184. 6. White SN, Yu Z, Tom JF, et al. In vivo marginal adaptation of cast crowns luted with different cements. J Prosthet Dent. 1995;74:25-32. 7. White SN, Yu Z. Physical properties of fixed prosthodontic resin composite luting agents. Int J Prosthodont. 1993;6: 384-389.

Conclusion
Although RMGI cements are not the ‘Holy Grail’ of cements, when indicated for the broad range of restorations noted in this article, they provide the clinician with a tested and proven formulation when cementing their laboratory-fabricated restorations. RMGI cements are less vulnerable to early moisture contamination. Resin-modified cements have many different clinical indications, making them an excellent choice for placing a wide variety of restorations.

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